Claims Auditor

Claims Auditor75 Vanderbilt Ave, Staten Island, NY 10304, USAReq #1153Friday, June 14, 2024Centers Plan for Healthy Living's goal is to create the ultimate healthcare experience that provides our members, their families, healthcare decision makers, and general caregivers with the guidance and plans they need for healthy living.

Individualized professional and personal growth is a primary focus at CPHL. With various teams to match the unique strengths of each individual, tiered roles to support the advancement, and with opportunities for cross-training and education, CPHL is the place for a fulfilling long-term career.

JOB SUMMARY : Responsible for the auditing functions of Centers Plan for Healthy Living (CPHL) claims. Collaborates with other Health plan departments and Management to ensure claims are processed in accordance with Federal, State and CPHL established guidelines and / or policies and procedures.

Provides feedback or suggestions to enhance current processes and / or systems; works under general supervision.PRIMARY RESPONSIBILITIES : Conducts monthly audits of CPHL claims utilizing CPHL guidelines, policies and procedures or any other regulatory requirements.

Follow defined audit processes and keep up to date with departmental changes in conducting quality reviews.Ensure the consistent use of current codes, correct information, documentation and departmental procedures by monitoring their use and identifying any deficiencies.

Prepare summaries for management of quality review results, including basic analysis of identified trends.Analyzes audit results to recommend system or procedural changes to increase claim accuracy and / or identify opportunities for workflow enhancements.

Evaluates Prospective Payment System (PPS) (e.g. APC, DRG, etc.) grouping and pricing information.Meets individual and departmental standards in regards to quality and productivity.

Strong organizational, analytical and writing skills.Excellent verbal and communication skills.Maintain good working relationships within and outside of the department.

Provides expertise and assistance relative to provider billing and payment guidelines consistent with CPHL policies and procedures and State or CMS guidelines.

Performs other duties and special projects as assigned and directed.EDUCATION AND EXPERIENCE : EducationRequired : BA / BS degree in a financial field or equivalent healthcare experiencePreferred : Type of ExperienceRequired : 2+ years of claim processing experience with a Medicaid / Medicare Health Plan.

Preferred : Experience in health insurance product environment.Specific Technical SkillsRequired : Proficiency with MS applications, including but not limited to Word, Excel, OutlookCertifications / Licensure : Required : n / aKnowledge and Skills : Effective presentation skillsExcellent verbal and written communication skillsMust be able to participate in meetings with all levels of management within the organizationDetail oriented, excellent follow upAbility to multi-task in a fast paced environmentMust be service oriented, quick learner, team playerAppreciation of cultural diversity and sensitivity toward target populationPreferred : SCOPE INFORMATIONDirect Reports : n / aPHYSICAL REQUIREMENTS : The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification.

They should not be construed as an exhaustive list of all responsibilities, duties and skills required.Centers Plan For Healthy Living is committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our employees and our business.

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law and will not be denied employment.

Other detailsPay Type HourlyMin Hiring Rate $25.64Max Hiring Rate $28.21Apply Now75 Vanderbilt Ave, Staten Island, NY 10304, USA