Job Summary:

• Develop and manage the audit process and delivery of assigned audits in line with agreed parameters reporting back to the Senior Claims Manager.
• Responsible for collating, checking and analysing claims files on a continuing basis, providing constructive feedback and coaching were required.
• Identify if and where processes are not working as per operating procedures, FCA principles and binding authority agreement
• Liaise with the Senior Claims Manager to further develop processes
• Liaise with managerial and front-line staff to present findings and recommendations where required
• Identify and evaluate areas of exposure, trends, potential problems and training requirements within the Claims Department.
• Manage the tracking and closeout of any audit issues, liaising with the Claims team to ensure adequate solutions, prevention methods are found, and relevant processes are updated.
• Undertake an Audit Risk Assessment at least annually to ensure audit and sampling processes align with Claims department objectives and strategy.
• Report on any issues identified and document the auditing findings to the Senior Claims Manager.
• Highlight and assist with training requirements for competency levels within the claims department to the Senior Claims Manager.
• Maintain productive professional relationships within the Claims team and with other key internal and external stakeholders.
• Ensure that staff are aware of the FCA requirements in relation to claims handling for ICOBS.

Skills on Resume: 

• Audit and Compliance Knowledge (Hard Skills)
• Analytical Skills (Hard Skills)
• Communication and Interpersonal Skills (Soft Skills)
• Problem Solving and Critical Thinking (Soft Skills)
• Process Improvement (Hard Skills)
• Training and Coaching (Soft Skills)
• Project Management Skills (Hard Skills)
• Documentation and Reporting (Hard Skills)

Job Summary:

• Complete assigned audits accurately and within a set time period
• Participate in special events and audits and submit claim corrections
• Conduct calibration discussions with managers to ensure the Claim Department has consistency in understanding and application of file handling expectations
• Respond to claim’s leadership questions and inquiries in a timely manner with accuracy
• Participate in intra-team calibration sessions to ensure necessary calibration is included in this function
• Maintain monthly and quarterly reporting with management over the assigned region and specialty, including assessment of action items and evaluation of action plans, expertise, and utilization of the audit tool
• Interpret and apply coverage issues accurately with a full understanding of the requirements surrounding good faith file handling
• Communicate effectively with all levels of employees, from front line claims representatives to department and company leaders
• Ensure that the Claims team are working in line with the binding authority agreements with insurers and maintain strict adherence to regulatory requirements.
• Ensure the maintenance of adequate records to demonstrate compliance with FCA requirements ICOBS 8.1.
• Develop and maintain a continual monitoring of claims handling process in line with ISO 9001:2008 internal Operating Procedures OP10.

Skills on Resume: 

• Audit Compliance (Hard Skills)
• Event Participation (Hard Skills)
• Calibration Discussions (Soft Skills)
• Timely and Accurate Responses (Hard Skills)
• Intra-Team Calibration (Hard Skills)
• Reporting and Evaluation (Hard Skills)
• Coverage Interpretation (Hard Skills)
• Effective Communication (Soft Skills)

Job Summary:

• Audit all patient accounts from the previous day to ensure documentation is correct, paperwork is completed and the patient ledger reflects actual services rendered
• Take appropriate adjustments as discussed with the office Practice Manager
• Submit clean claims to insurance in a timely manner for all assigned offices
• Keep up with DentalExchange on a daily basis to ensure that all errors are addressed in a timely manner
• Appeal all denials by the end of the following business day
• Respond to all requests for additional information from insurance by the end of the following business day
• Complete 15-30 day Outstanding Claims Report at least once per month
• Create and complete weekly Unsent Claims report
• Submit secondary claims for assigned locations where primary claims have been received based on daily posting message from Posting Specialist
• Fill out weekly Claims Auditor scorecard as well as monthly and quarterly check-ins
• Maintain a detailed knowledge of where all claims auditor and collections metrics for assigned offices stand and why at all times.
• Performs special project audits and reviews as requested by other departments/regions.
• Maintains a minimum audit accuracy rate.

Skills on Resume: 

• Attention to Detail (Hard Skills)
• Organizational Skills (Hard Skills)
• Knowledge of Medical Billing and Coding (Hard Skills)
• Analytical Skills (Hard Skills)
• Time Management (Hard Skills)
• Communication Skills (Soft Skills)
• Problem-Solving Skills (Soft Skills)
• Adaptability and Flexibility (Soft Skills)

Job Summary:

• Evaluates claims adjudication using standard principles and state specific policies and regulations in order to ensure accurate and timely claims adjudication
• Performs moderately sophisticated claim audits on a routine basis for payment accuracy by following regulatory standards, and business policies
• Assist manager with validation of health plan findings
• Conducts quality assurance audits for claim adjustments, refunds and provider disputes
• Performs focused reviews and provides reports to the Compliance team
• Tracks and monitors all audit scores in database
• Assists in preparing audit reports
• Performs monthly claims audits for claims personnel.
• Maintain accurate records of audit results and identify document patterns of errors made by claims personnel
• Ensure adequate security measures are in place and authority levels and overrides are adhered to
• Ensure that medical review flags are preliminary audit purposes, are in place, reinforced

Skills on Resume: 

• Knowledge of Claims Adjudication (Hard Skills)
• Claim Auditing Skills (Hard Skills)
• Validation Assistance (Hard Skills)
• Quality Assurance Audits (Hard Skills)
• Reporting and Documentation (Hard Skills)
• Database Management (Hard Skills)
• Analytical Skills (Hard Skills)
• Compliance and Security Measures (Hard Skills)

Job Summary:

• Analyzes and reports on data through a working knowledge of ICD-9. HCPCS, and CPT coding guidelines, healthcare finance regulations and various regulatory agency standards.
• Assists in the writing and implementation of Business Rules. 
• Performs testing of programmings which have a claim impact.
• Completes required reporting and sends completed reports to the Maryland Insurance Administration and the Department of Healthcare Finance in a timely manner.
• Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. 
• Complies with governmental and accreditation regulation.
• Develops, implements, and maintains claims auditing policies and procedures and auditing infrastructure.
• Identifies fraud and abuse cases and reports findings to the Compliance department.
• Leads and implements improvements, enhancements, updates and modifications to systems and processes that have a claim impact.
• Manages the claims audit function of MSFC by working with internal departments to run audit data, perform claim audits and medical record audits, and research and resolve billing and payment issues.
• Participates in meetings, on committees, and assists in educating internal staff on coding and billing principles.
• Participates in multidisciplinary quality and service improvement teams and committees. 
• Participates in meetings and on committees as requested, and represents the department and hospital in community outreach efforts.

Skills on Resume: 

• Medical Coding Knowledge (Hard Skills)
• Regulatory Compliance (Hard Skills)
• Business Rules Implementation (Hard Skills)
• Testing and Reporting (Hard Skills)
• Claims Auditing (Hard Skills)
• Fraud and Abuse Detection (Hard Skills)
• Process Improvement (Hard Skills)
• Team Participation and Communication (Soft Skills)

Job Summary:

• Performs quarterly Maryland Insurance Administration audits for MSFCs administrative service providers, which includes vision, pharmacy, lab, and substance abuse.
• Records audit results and relays audit conclusions and corrective actions to Supervisor.
• Reviews and makes decisions on claims appeals.
• Runs reports to identify claims data required for audits.
• Supports MSFC compliance initiatives by conducting fraud, abuse, and other audits.
• Tests any changes made to system with a claim impact. 
• All testing needs to be recorded and stored. 
• Ensure that claims are reprocessed after fix is in place.
• Works closely with Finance department during external audits.
• Works closely with TPA to research and resolve issues and follows up to ensure action plans are implemented.
• Works with Provider Relations Dept. to assist in educating physicians and providers on billing issues found in claims or medical record audits.

Skills on Resume: 

• Auditing Skills (Hard Skills)
• Claims Appeals (Hard Skills)
• Data Analysis (Hard Skills)
• Compliance and Fraud Detection (Hard Skills)
• Testing and Quality Assurance (Hard Skills)
• Record Keeping and Documentation (Hard Skills)
• Collaboration and Communication (Soft Skills)
• Educational Outreach (Soft Skills)

Job Summary:

• Work with multiple departments in the hospital to audit and/or evaluate compliance with federal and state rules and regulations related to claims.
• Track outstanding issues identified in claims compliance audits, issue reports and appropriate recommendations and/or conclusions to the Compliance/Privacy Officer, department leaders, and the Corporate Compliance Committee.
• Assist in the development, execution and follow-up of action plans, education to improve performance.
• Performs routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory standards and timelines, business policy, contract, appropriate coding, and system configuration with ability to extract and audit exception audit reports.
• Research claim processing problems and errors to determine origin and appropriate resolution. 
• Prepare reports and summarizes observations for management summarizing observations and recommendations.
• Identifies and escalates issues related to instructional material that is inaccurate, unclear or contains gaps. 
• Provides recommendations for correction of this material. 
• Confers with management to assess training needs in response to changes in policies, procedures, regulations, and technologies.
• Performs queries on relevant claims systems to obtain relevant information for audits
• Validates claims data, member data, provider data against information from claims processing or business processing systems to ensure that data/decisions/payment and recovery/settlement information is accurate
• Analyzes claims data against applicable policies and regulations to identify potential issues (e.g., member benefits, provider contracts, billing anomalies, payment accuracy, claims processing system issues, state mandates)
• Reviews history of related claims to pull in and understand additional claims-related information

Skills on Resume: 

• Auditing and Compliance Evaluation (Hard Skills)
• Issue Tracking and Reporting (Hard Skills)
• Action Plan Development (Hard Skills)
• Problem Resolution (Hard Skills)
• Data Analysis and Validation (Hard Skills)
• Reporting and Summarizing (Hard Skills)
• Policy and Procedure Review (Hard Skills)
• Training Needs Assessment (Soft Skills)