Lead Medical Claims Auditor I

About the role

This is a full-time, work-from-home position providing backup support to the Supervisor for reports, questions, policy development and maintenance, and process improvements. The role oversees department workflow and assigns tasks as needed, assisting with external audits.

Responsibilities

• Provide backup and support to supervisor of unit, including monitoring assignments and overtime, evaluating performance, training, communicating policy to staff, and answering questions from Claims Auditors and Reinsurance Specialists.
• Analyze situations and communicate effectively in a fast-paced environment that includes a wide variety of job duties.
• Provide accurate information in a professional manner.
• Exercise judgment, initiative, and discretion in confidential and sensitive matters.
• Assist in planning, organizing, and directing the activities and workflow of the department.
• Responsible for quality and continuous improvement within the job scope.
• Answer inquiries from other departments, including Customer Service, Claims, Billing & Eligibility, Accounting, and HealthCare Services.
• Perform related duties such as communicating concerns, issues, and ideas for improvement to Supervisor, developing, documenting, and maintaining department policies and procedures, claim adjustments and file reviews, assisting with External Audits, monitoring and maintaining unit spreadsheets, assisting with Reinsurance, Auditing and Claims Processing as needed, contacting physicians, dentists, hospitals, and other providers when necessary, reviewing, updating, and becoming familiar with new and revised benefit information or claim processing policies and procedures, and assisting in monitoring large projects received from other departments.

Requirements

• High School diploma or equivalent.
• Minimum of 2 years of experience as a Claims Auditor.
• Excellent reading, verbal and written communication skills and ability to interact professionally, patiently, and courteously.
• Strong analytical, problem-solving, and decision-making skills with demonstrated ability to handle and resolve complaints, correct errors, and resolve departmental issues in accordance with Moda contracts and company policies.
• 10-key proficiency of 105 wpm net on a computer numeric keypad.
• Type a minimum of 25 wpm net on a computer keyboard.
• Ability to work well under pressure in a complex and rapidly changing environment.
• Ability to maintain confidentiality and project a professional business image.
• Working knowledge of all plan types, contract and policies affecting claims and customer service.
• Proficiency in all internal claims systems and Microsoft Office applications.
• Demonstrated ability to consistently organize work and time to meet deadlines and complete work in a timely manner.
• Ability to come to work on time and daily.
• Ability to work with frequent interruptions and demonstrate professional leadership.
• Demonstrated strong, effective, and diplomatic interpersonal skills with employees of all levels, and ability to participate effectively as a team player.
• Maintain confidentiality and project a professional business presence and appearance.
• Be flexible and accepting of change.

Qualifications

Qualifications are based on the requirements listed above. Applicants who do not meet these qualifications will only be eligible for the low end of the pay range.

Skills

Skills are not specified in the job posting.

Benefits

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Pay

$20.88- $23.49 hourly, DOE.

Schedule

This is a full-time, work-from-home position.