Claims Auditor

Job Description Summary

This position reports to the Supervisor of Payment Integrity and performs in-depth audits to ensure existing health (medical/dental) benefit plans of Western Growers Assurance Trust and Pinnacle Claims Management, Inc. clients are in compliance with the respective employers' summary plan descriptions.

Qualifications

• BS/BA degree preferred and a minimum of one (1) to three (3) years of recent experience as a medical/dental claims auditor, preferred.
• A minimum of three (3) years’ experience processing group health claims, highly desired.
• Knowledge of the Patient Protection and Affordable Care Act (PPACA), Health Insurance Portability and Accountability Act (HIPAA), Consolidated Omnibus Budget Reconciliation Act (COBRA), California-COBRA, and Employee Retirement Income Security Act (ERISA) regulations.
• Knowledge of Current Procedural Terminology (CPT) and International Statistical classification of Diseases and Related Health Problems (ICD-10 & ICD-9) and medical terminology.
• Exceptional understanding and interpretation of summary plan descriptions of employee medical/dental benefits.
• Good ability to interpret provider contracts.
• Proven ability as a self-starter to manage timelines and commitments.
• Proficient in end-user software, e.g., word-processing and spreadsheets.
• Exceptional written and verbal communication skills.
• Strong knowledge of business math.

Duties and Responsibilities

• Perform routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory and timelines standards, business policy, and contract terms.
• Ensure appropriate coding and system configuration of claims with the ability to extract and audit exception audit reports.
• Research claim processing problems and errors to determine their origin and appropriate resolution.
• Prepare reports and summarize observations and recommendations for management.
• Participate in communication with management regarding trends in order to improve claims processing accuracy and documented business rules for incorporation into training programs, policies, and procedures.
• Perform special project audits and reviews as requested by other departments/regions.
• Identify and escalate issues related to instructional material that is inaccurate, unclear or contains gaps and provide recommendations for correction of this material.
• Confer with management to assess training needs in response to changes in policies, procedures, regulations, and technologies.
• Provide technical support, training assistance, and expertise to claims staff or other departments as determined through audit findings.
• Support and assist management team in updating department policies and guidelines.
• Assist with user acceptance testing (UAT) for new system enhancements.
• Prepare monthly audit trend report for management that reflects primary errors, the root cause for the errors, and suggested improvement plans to improve the accuracy of claims processing.
• Identify staff training needs, support training development, and coordinate ongoing or ad-hoc training.
• Support and assist management team in updating department policies and guidelines.
• Assist with user acceptance testing (UAT) for new system enhancements.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and assist management team in updating department policies and guidelines.
• Support and