Claims Quality Auditor audits claims for coding accuracy, benefit payment, contract interpretation, and compliance with policies and procedures. Selects claims through random processes and/or other criteria. Being a Claims Quality Auditor makes recommendations to improve quality, workflow processes, policies and procedures. Typically requires an associate degree. Additionally, Claims Quality Auditor typically reports to a supervisor or a manager. The Claims Quality Auditor gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Claims Quality Auditor typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
POSITION SUMMARY/RESPONSIBILITIES
Responsible for development and maintenance of claims auditing program for all lines of business to improve claims processing standards and to monitor the quality of service delivered to our customers. Identifies processor and phone representative training needs that can be used to improve performance. Requires knowledge of claims processing for HCFA and UB92 for both commercial and Medicaid programs and knowledge of CFHP claims payment processing system, Amisys.
EDUCATION/EXPERIENCE
High school diploma or equivalency is required. Minimum of five years experience in insurance, medical or managed care environment including two years of claim processing experience required. Previous auditing and/or Amisys experience preferred.
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