Description
Quality Control Auditor (medical claims)
Duration: 5-month assignment
Location: Rancho Cucamonga, CA 91730
Job Number: 78604
Position Summary:
Ensures the integrity of outside medical payments for the Organization through verification of the accuracy of data-entered information and by auditing service related information and invoice adjudication/payment for compliance with contract terms and Department and Regional Policies and Procedures.
Duties:
- Auditing complex medical claims for our OPA population and high dollar claims
- Reviewing rebuttals to audited claims by the auditor
- Auditing Hospital and Medical office encounters daily, and provides findings to the Director
- Ensures that audit staff tests payments for accuracy according to departmental policies and management guidelines
- Traces sources of inaccuracies; reports and proposes remedial action to appropriate management
- Ensures charity Care (MFA) encounters
- Prepares formal statistical summaries to department manager of findings and recommendations
Required Education, Experience, and Skills:
- Bachelor's degree, or equivalent experience, in Business Administration or related field
- 2-3 years' claims processing experience and auditing experience
- Proficient knowledge of computers, Word, Excel
- Strong mathematical skills
- Medical terminology and knowledge of medical billing practices
- Good oral and written communication skills
- Works well with team members
- Flexible
- Willing to do what it takes to get the job done accurately
Desired Experience and Skills:
- Prior experience in account payable/claims environment
- 3+ years medical claims processing experience on multiple products such as HMO, PPO, POS, Traditional/Indemnity, etc. as well as various pricing fee schedules (eg, DRG, Stoploss, Transplant, etc.)
- 5+ years medical claims auditing experience in auditing all products (eg, HMO, PPO, POS, Medi-Cal, Medicare, etc.) Property & Casualty claims processing experience does not qualify