Claims Auditor

  • Full Time
  • Pasadena

Imperial Management Administrators Services

Claims Auditor conducts audits for management to assess effectiveness of controls, accuracy of claims records and payments, efficiency of claims operations, and to recover claims overpayments. Audits all paid and denied claims to identify processing errors and coordinates with management to develop processing standards. Identifies and reports suggestions for operational efficiency improvements to management. Implements auditing guidelines and processes and creates policies and procedures for the internal auditing process. Implements random auditing process or hard copy claims. Develops forms for notification of audit results to claims staff. The Claims Auditor develops and runs claims processing system reports to assist in periodic monthly audit reporting. Claims Auditor also assists in the administration of recoveries for the overpayment of claims.

Duties and Responsibilities

· Performs routine and moderately complex audits on individual, random, training and focused claims to identify exceptions to established claims adjudication requirements.

· Researches claim processing problems and errors to determine their origin and appropriate feedback to examiners, trainees and distribution to management.

· Participates in communication with claims department management regarding results of claims audit process, in order to improve claims processing and resolution.

· Observes employee claims processing techniques in order to provide feedback to employees and management on uniform application of guidelines and processes.

· Provides qualified data for incorporation into training programs, policies and procedures.

· Completes other designated special projects with the time period assigned by department management.


· Must have at least 5+ years of applicable healthcare claims adjudication experience within the managed care industry for a level I or II and at least 4 years for senior level claims.

· Associate’s degree (A.A) or equivalent from two year college of technical school; some college courses, or six months to one year related experience and/or training; or equivalent combination of education experience.

· Claims Auditor must have experience with EZ-Cap database software or comparable claims processing system and Windows 2000, including Outlook and Excel software.

· Must be familiar with ICD-9, HCPCS, CPT coding, ASC, APC and MS-DRG pricing

· Must be familiar with CMS, DHMC Regulations, facility and professional claim billing practices.

· Must have knowledge of multi-product line claims adjustment experience.

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