Claims Auditor 26-00030

Under the direction of the Provider Claims Resolution & Recovery Supervisor, the Provider Recovery Auditor is responsible for the audit and recovery of claims overpayments including COB and third-party liability.

Major Functions (Duties and Responsibilities)

1. Initiate and expand recovery opportunities through provided audit results, Provider calls, Third Party Liability and CCS eligible services.
2. Audit payment errors that result in Provider refund checks to properly apply funds and determine the root cause.
3. Communicate with and answer Provider inquiries and/or Provider Disputes regarding the reason for the refund request based upon claims processing guidelines, contractual agreements involving the use of established payment methodologies, Division of Financial Responsibility, and regulatory guidelines.
4. Promote teamwork and maintain effective working relationships with others throughout the organization.

• Four (4) years claims processing experience including Medicare and Medi-Cal
• Two (2) years of experience auditing claims in a managed care environment including contract and financial DOFR interpretation
• Experience with MS Office applications

Key Qualifications

• Strong analytical and problem-solving skills
• Must be able to review cause and impact of problems and recommend realistic solutions both in writing and in meetings
• Microsoft Office including being able to manipulate large data sets in Excel files
• Excellent oral and written communication skills