The Claims Auditor will audit and monitor claims for accuracy, benefit payment, contract interpretation and compliance with policies and procedures.
Conducts random claims audits, high dollar claim audits, focus audits on a pre and post-payment basis and records audit findings. Calculates processor quality percentages as directed by leadership using audit results.
Conducts and documents specialized audits as needed and as requested by claims supervisors such as high dollar audits, out of network audits, new employee, employee quality improvement, or audits deemed by the cost containment claims committee.
Maintains working knowledge of Medicaid, Commercial, and Medicare rules and regulations as applicable to lines of business being audited as well as knowledge of CPT, ICD-9/ICD-10 coding, HCPCS and DRGs.
Utilizes resources such as payment guidelines, Medicaid, Commercial plans, CMS guidelines and other resources to validate audit parameters and results as well as provide leaders with references for education and performance management.
Assists leadership staff in developing and maintaining specific work procedures, policies and procedures and process improvement projects.
Assists claims leadership staff in developing and maintaining specific work procedures, policies and procedures and process improvement projects.
Two years of experience in a claims processing environment using various claims pricers and ability to understand provider contract; language and terms.Ability to successfully impart information in a group or individual setting.Strong written and verbal communication skills.
Strong working knowledge of Microsoft Office software (Word, Excel, Access). In-depth knowledge and experience with Medicaid, Commercial and Medicare health plans. Ability to work independently and pay attention to details.
Two years of claims processing CMS1500 professional forms, UB facility forms and dental forms preferred.
Additional related education and/or experience preferred.
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.