Claims Auditor II, South San Francisco, CA
CLAIMS AUDITOR II
The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Claims Auditor II to perform concurrent and retrospective review of claims processed by all areas of the Claims Department with an emphasis on highly complex edits and areas deemed to be in need of close oversight. Train/retrain staff on policies and procedures related to claims processing; and log, track and report all audit activity and provide information to the Claims Managers and others as required.
The essential duties and responsibilities will include the following:
- Perform an appropriate number of audits on a timely basis, based on retrospective accuracy percentages of each incumbent.
- Review internal processes, including analysis of current reporting criteria for redundancy and importance. Perform concurrent, retrospective and preventive review of claims processed by all levels of Examiners, claim processes and claims transmitted via OCR
- Weekly review of claims from sensitive providers, high-dollar claims, and random RA audits
- Handle responses/appeals to audit findings
- Assist in the review and maintenance of auditing guidelines, including the audit tracking database, and make recommendations to the Claims Managers to increase the accuracy of claims processed
- Log, track, and report all audit and productivity results and provide information to the Claims Managers and others as needed.
- Recommend areas in need of additional training and/or close oversight based on the trending and analysis of audit results.
- Handle urgent and/or sensitive issues, including PCIs, projects, and escalated calls.
- Maintain working knowledge of policies and procedures for standard work processes in the Claims Department.
- Process claims on an occasional basis to maintain skills
- Perform other duties as assigned.
Education and Experience: Three (3) years of experience in health claims processing/adjudication. A college degree in a health or business related field is preferred.
Knowledge of: Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint. Medicare and Medi-Cal programs.
Ability to: Work cooperatively with others. Work as part of a team and support team decisions. Communicate effectively, both verbally and in writing. Adapt to changes in requirements/priorities for daily and specialized tasks Train or coach others. Work in a fast-paced, highly pressured, and changing environment. Analyze/evaluate information. Interpret policies and procedures. Produce basic logs and reports. Interact effectively with others and be a team player. Communicate efficiently orally and in writing. Organize workload. Work independently using sound judgment.
Compensation and Benefits
Starting Compensation Range: - Depending on Experience
Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage. Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits. Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.
How to Apply
Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: email@example.com or via fax: (650) 616-8039. File by: Continuous until filled. The Health Plan of San Mateo is proud to be an Equal Opportunity Employer and encourages minority candidates of all backgrounds to apply.
Submissions without a Cover Letter and Salary Expectations may not be considered.