Claims Auditor

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:

Education

Required: BA/BS degree in a financial field or equivalent healthcare experience   

Preferred:   

Type of Experience                                          

Required:   2+ years of claim processing experience with a Medicaid/Medicare Health Plan.

Preferred:   Experience in health insurance product environment.

Specific Technical Skills

Required:    Proficiency with MS applications, including but not limited to Word, Excel, Outlook

Certifications/Licensure:

Required:    n/a

Knowledge and Skills:

• Effective presentation skills
• Excellent verbal and written communication skills
• Must be able to participate in meetings with all levels of management within the organization
• Detail oriented, excellent follow up
• Ability to multi-task in a fast paced environment
• Must be service oriented, quick learner, team player
• Appreciation of cultural diversity and sensitivity toward target population

Preferred:

SCOPE INFORMATION

# Direct Reports:      n/a                 

PHYSICAL 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.