claims auditor.

POSITION SUMMARY

The Claims Auditor assists in the Claims Department by analyzing procedures, policies and reports; ensures appropriate payment of claims and maintenance of the claims system as necessary.

SPECIFIC SKILLS NEEDED

Knowledge of HMO/or IPA operations; medical terminology; ICD-10, RVS, and CPT coding knowledge; knowledge of Medicare and Medi-Cal guidelines; 10-key skills by touch; excellent communication skills; knowledge of system applications; ability to function effectively under time deadlines; strong organizational skills.

Required:

Formal training will be indicated by a high school diploma or equivalent; four years medical claims processing.

Preferred:

- Department Management to list.

DUTIES AND RESPONSIBILITIES

1. Safeguards and preserves the confidentiality of patient's protected health information in accordance with State and Federal (HIPAA) regulatory requirements, hospital and departmental policies.

2. Ensures a safe patient environment and adherence to safety practices per policy.

3. With consideration to age, employee utilizes the approved process to resolve biophysical, psychological, educational and environmental needs of patient/significant other when administering care.

4. Assist the Claims Director in the training and education of the Claims department staff

5. Coordinate the generation and review of claims audit, status and pending claims reports ensuring authorized claims are paid in accordance with company guidelines

6. Investigate, process and track payment adjustments including refunds, overpayments and underpayments

7. Act as a confidential and professional resource for group providers and other staff.

8. Act as a resource for providers, members, insurance carriers, attorneys and co-workers, researching and responding to questions in a timely manner

9. Create, maintain and generate system reports

10. Interface with the Claims Director to ensure claims processing functions meet legal and contractual requirements with regards to health plan audits

11. Prepare and present weekly and monthly reports reflecting staff and departmental quality statistics

12. Review and audit member liability denials and Provider Dispute Resolution claims to ensure compliance with regulatory requirements and passing audit scores from health plans

13. Perform other duties as assigned

TEAMWORK/CUSTOMER SERVICE RESPONSIBILITIES

1. Customer Service Values and Behaviors:

1.1 Value: Each person is treated with respect, dignity, fairness and compassion.

Behavior: Performance is acceptable when everyone is promptly greeted with a smile in a warm and caring manner using the person's name whenever possible. No matter how I feel, I display a caring attitude.

1.2 Value: Each person displays loyalty and pride in PIH Health and upholds the confidentiality of patients, visitors, physicians, and co-workers.

Behavior: Performance is acceptable when concerns/problems with fellow employees and customers are not discussed with anyone other than the person involved or the supervisor. Customer issues and ideas are listened to and appropriate follow up occurs to create a satisfied customer. I do not make excuses. I do not demean other people or departments.

1.3 Value: Each person demonstrates commitment to open communication.

Behavior: Performance is acceptable when openness and acceptance of constructive criticism occurs. Positive communication occurs by complimenting and expressing appreciation to others. I will listen and encourage others to express ideas and opinions.

1.4 Value: Each person demonstrates pride in the physical appearance of all PIH Health properties.

Behavior: Performance is acceptable when the initiative is taken to maintain a clean and safe environment. I conduct myself in a manner which respects and preserves equipment and the physical plant. I do not walk by spills, trash or unsafe conditions without assuring that they are attended to promptly by me or appropriate personnel.

PERSONAL QUALITIES

- Department Management to list.

COMMUNICATION

- Talking or hearing essential to communicate with patients and staff.

- Good communication skills; read, speaks and writes English fluently.

- Bilingual skills in Spanish/Chinese preferred


Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact HRsupport@randstadusa.com.

Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).

This posting is open for thirty (30) days.

Qualified applicants in San Francisco with criminal histories will be considered for employment in accordance with the San Francisco Fair Chance Ordinance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance.