Security Health Plan Claims Auditor - Remote Job at Marshfield Clinic Health System
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Job Title:
Security Health Plan Claims Auditor - Remote
Cost Center:
682891379 SHP-Claims
Scheduled Weekly Hours:
40
Employee Type:
Regular
Work Shift:
Mon-Fri; day shifts (United States of America)
Job Description:
JOB SUMMARY
The Claims Auditor is responsible for performing payment, procedural accuracy, turnaround time, compliance and operational audits as directed by management. The Claims Auditor has working knowledge of the overall aspects of claim processing, both in and outside of Security Health Plan. Audit responsibilities include applying effective, appropriate and efficient audit procedures in collecting, analyzing and reporting concise and relevant findings.
ESSENTIAL JOB FUNCTIONS
1. Develops and maintains a knowledge base of CPT coding guidelines, ICD codes, healthcare common procedure coding system (HCPCS) codes, use of modifiers, documentation guidelines, CMS policy, Medicaid rules, and other reimbursement guidelines, to ensure the audit of charges is based on the appropriate guidelines for the insurance carrier.
2. Develops and maintains thorough knowledge of Audit application, SHP legacy applications and SHP QNXT application, to efficiently complete assignments and accurately enter data regarding audits into the auditing database.
3. Conducts monthly audits of processed claims to verify accuracy of processing, financial, procedural and turnaround time.
4. Investigates and reports claim variances to the appropriate SHP or Security Administrative Services (SAS) staff for correction.
5. Conducts focused or ad-hoc audits, as determined by business needs.
6. Reviews medical records to determine the appropriateness of medical charges on claims that are chosen for complex audit review.
7. Analyzes and resolves complex claim processing problems, to ensure timely resolution of questions, audits or system issues.
8. Regular attendance is required in order to carry out the essential functions of the position.
9. Reviews and meets ongoing competency requirements of the role to maintain the skills, knowledge and abilities to perform, within scope, role specific functions.
JOB QUALIFICATIONS
EDUCATION
For positions requiring education beyond a high school diploma or equivalent, educational qualifications must be from an institution whose accreditation is recognized by the Council for Higher Education and Accreditation.
Minimum Required: High school diploma or equivalent. Successful completion of the following courses per departmental procedures, within one year of hire: current procedural terminology (CPT), current international classification of diseases (ICD), health care procedure coding system (HCPCS) and medical terminology.
Preferred/Optional: Associate degree in business, medical or related field. Successful completion of the following courses per departmental procedures at time of hire: current procedural terminology (CPT), current international classification of diseases (ICD), health care procedure coding system (HCPCS) and medical terminology.
EXPERIENCE
Minimum Required: Three years’ experience related to health insurance claim processing. Three years’ experience related to CPT/HCPCS and current ICD coding. Demonstrated proficiency with analytical problem solving, written and oral communications and the Microsoft Office Suite. Working knowledge of anatomy & physiology.
Preferred/Optional: One year experience in claims auditing.
CERTIFICATIONS/LICENSES
The following licensure(s), certification(s), registration(s), etc., are required for this position. Licenses with restrictions are subject to review to determine if restrictions are substantially related to the position.
Minimum Required: Certified Professional Coder (CPC) or Certified Professional Coder – Payer (CPC-P) certification awarded by the American Academy of Professional Coders (AAPC) within three years of hire based on the department position the resides in.
Preferred/Optional: Certified Professional Coder (CPC) or Certified Professional Coder – Payer (CPC-P) certification awarded by the American Academy of Professional Coders (AAPC) at time of hire.
Given employment and/or payroll requirements of individual states, Marshfield Clinic Health System supports remote work in the following states:
Alabama
Alaska
Arkansas
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Michigan
Minnesota
Mississippi
Missouri
Nebraska
North Carolina
North Dakota
Ohio
Oklahoma
South Carolina
South Dakota
Tennessee
Texas
Utah
West Virginia
Wisconsin
Wyoming
Marshfield Clinic Health System will not employ individuals living in states not listed above.
Marshfield Clinic Health System is committed to enriching the lives of others through accessible, affordable and compassionate healthcare. Successful applicants will listen, serve and put the needs of patients and customers first.
At Marshfield Clinic Health System, we are fully committed to addressing health equity, diversity and inclusion for our employees and providers, our patients, and the communities we serve. We believe that every individual should have the opportunity to attain their highest level of health. We embrace diversity and welcome differences in who we are and how we think. We believe that any individual or group should feel welcomed, respected and valued.
View our Equity and Inclusion Statement here
.
Exclusion From Federal Programs: Employee may not at any time have been or be excluded from participation in any federally funded program, including Medicare and Medicaid. This is a condition of employment. Employee must immediately notify his/her manager or the Health System’s Compliance Officer if he/she is threatened with exclusion or becomes excluded from any federally funded program.
Marshfield Clinic Health System is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.
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