Claims Auditor Resume Samples

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C Schoen

Chelsie

Schoen

77304 Osinski Summit

Phoenix

+1 (555) 272 9365

77304 Osinski Summit

Phoenix

Phone

p +1 (555) 272 9365

Experience Experience

Boston, MA

Claims Auditor

Boston, MA

Krajcik Group

Boston, MA

Claims Auditor

Provides accuracy feedback to processors/examiners and claims management
Provide feedback on trends to Clinical Admin Director and Account Manager
Communicate training issues to management as identified through audits and adjustments
Report audit results and error trends to management
Create and foster a team environment that encourages initiative, creativity, and solutions for overall company goal achievement
Providing instructive and constructive feedback
Works independently and without significant guidance

Houston, TX

Delegated Claims Auditor

Houston, TX

Abbott-Runolfsson

Houston, TX

Delegated Claims Auditor

Claims processing timeliness, financial accuracy, interest payment accuracy, denial accuracy, etc
Eligibility Review to ensure systems are set up in accordance with current eligibility documentation for the processing of claims
Responsible for the development of Corrective Action Plans
Performs oversight-monitoring activities including analysis of monthly reports, as well as conducting trending analysis and review of Monthly Timeliness Reports
Facilitates ad-hoc meeting with delegates to discuss and proactively address identified issues
Promotes a Culture of Safety by adhering to policy, procedures and plans that are in place to prevent workplace injury, violence or adverse outcome to associates and patients
(For patient care providers) Provides nursing care, ensures an environment of patient safety, promotes evidence-based practice and quality initiatives and exhibits professionalism in nursing practice within the model of the ANCC Magnet Recognition Program®

present

Detroit, MI

Senior Claims Auditor

Detroit, MI

Powlowski and Sons

present

Detroit, MI

Senior Claims Auditor

present

Conducts claims investigations to insure proper billing practices from contracted and non-contracted providers
Performs special project audits and reviews as requested by other departments / regions
Keeps management apprised of issues that may arise
Assist in training new staff
Participates in Fraud & Abuse committee meetings
Reviews results timely and come to independent conclusions that can be explained clearly and supported through data
Participates in communication with Business Operations management regarding trends in order to improve claims processing accuracy and documented business rules for incorporation into training programs, policies and procedures

Education Education

Bachelor’s Degree in Accounting

Central Michigan University

Bachelor’s Degree in Accounting

Skills Skills

Strong attention to detail
Excellent organizational, time management skills and ability to multitask
Strong analytical skills and detail orientated
Working knowledge of Word and Excel and ability to perform Internet research
6) Basic knowledge of Microsoft office & Excel
Excellent knowledge of CPT, RBRVS, DRG, HCPCS and ICD-9 coding and regulations
Strong knowledge and understanding of Managed Healthcare
3) GREAT organizational skills
Excellent communication skills (written and verbal)
Strong organizational skills

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10 Claims Auditor resume templates

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Claims Auditor Resume Examples & Samples

3+ years of Claims experience in a Managed Care environment
Experience with analyzing data files to determine the reason claims are not processing in accordance with expected results and recommend solutions
Familiarity with Medicaid and Medicare regulations
Knowledge of ICD-9 and CPT4 coding and Medical terminology
Knowledge of coordination of benefits regulations
Evaluation and reconciliation skills

Senior Delegated Claims Auditor Resume Examples & Samples

Performs remote and onsite audits of all claim types processed by the delegates, including Ancillary-, Facility claims in order to ensure compliance to health plan, Federal, and State regulatory requirements for claims processing. Complete required audit reports, audit worksheets, and develop improvement action plans (IAPs) timely and accurately, and deliver audit results to the delegates. Audit Review includes, but are not limited to, the following processes
Claims processing timeliness, financial accuracy, interest payment accuracy, denial accuracy, etc
Performs CMS Part C Reporting requirements, including data validation, variance validation, and certification of Part C data collected from each delegate. Performs oversight-monitoring activities including analysis of monthly reports, as well as conducting trending analysis and review of Monthly Timeliness Reports. Facilitates ad-hoc meeting with delegates to discuss and proactively address identified issues. Provides consistent updates and reporting to Manager, and other key stakeholders on an ongoing basis for all business process optimization needs
Assesses and validates that all regulatory as well as health plan requirements are adhered to in the processing of claims transactions with delegated entities. Performs process mapping as needed to understand the upstream/downstream of quality concerns. Uses root cause analysis and associated tools for detecting errors occurring in high volume process transactions that have member impact, as well as regulatory implications. Initiates process improvement activities for remediation purposes
Responsible for the development and implementation of Improvement Action Plans to drive execution of remediation activities. Escalate issues as appropriate with manager and director. Conducts health plan remediation enforcement reviews (sanctions) for delegated provider groups. Conducts onsite operational assessments for onboarding potential delegation or delegation expansions as required
Associate’s Degree (or higher) or High School Diploma/GED w/ 7+ years experience Auditing the following claim types: Inpatient/outpatient/Ambulance or Anesthesia
5+ years of claims processing experience for the following claim types: In patient/outpatient/ Ambulance or Anesthesia
3+ years experience auditing the following claim types: In patient/outpatient/ Ambulance or Anesthesia
5+ years of experience with Medicare claims processing requirements and regulatory Prompt Pay Guidelines
Strong understanding of all aspect of the HMO and Delegated model
Previous experience in the development, implementation and monitoring of Corrective Action Plans
Experience utilizing Project Management skills including handling multiple work streams and projects simultaneously
Experience in collaborating and influencing outcomes at all levels across an organization, including Sr. Leadership and/or with delegated entities
Intermediate level proficiency utilizing Excel for Data Analysis
Ability to travel up to 70% of the time as required by the needs of the business

Delegated Claims Auditor Resume Examples & Samples

Eligibility Review to ensure systems are set up in accordance with current eligibility documentation for the processing of claims
Claims Processing Review to ensure that the claim was processed appropriately based on the full end to end review to source documentation
Performs CMS Part C Reporting requirements, including data validation, variance validation, and certification of Part C data collected from each delegate
Performs oversight-monitoring activities including analysis of monthly reports, as well as conducting trending analysis and review of Monthly Timeliness Reports. Facilitates ad-hoc meeting with delegates to discuss and proactively address identified issues. Provides consistent updates and reporting to Manager, and other key stakeholders on an ongoing basis for all business process optimization needs
Performs oversight-monitoring activities for the delegates, including analysis of monthly reports, as well as conducting trending analysis and review of Monthly Timeliness Reports. Facilitates ad-hoc meeting with delegates to discuss and proactively address identified issues. Provides consistent updates and reporting to Manager, and other key stakeholders on an ongoing basis for all business process optimization needs
Responsible for the development of Corrective Action Plans
5+ years of Claims Processing and Auditing experience for the following claim types: In patient/Outpatient/ Ambulance and Anesthesia
5+ years of experience with Medicare Claims Processing Requirements and Regulatory Prompt Pay Guidelines
Experience in collaborating and influencing outcomes at all levels across an organization and/or with delegated entities
Experience analyzing data and proposing remediation, as well as developing Corrective Action Plans in all variety of mediums (verbal, writing, PowerPoint) to a broad audience level across an Organization
Recent experience utilizing MS Word, Excel, Access and PowerPoint
Ability to travel up to 60% of the time as required by the needs of the business

Claims Auditor Resume Examples & Samples

Maintains a solid working knowledge of Healthplan and provider contracts, division of responsibility (DOFR), and CPT/ICD9 coding
Audits daily professional and facility claims for assigned groups
Flags claims for examiner errors
Researches system configuration against contracts and flag claims for system configuration errors
Creates Customer Service incidents to the Terms & Conditions department for system configuration issues
Applies McKesson Claim Check software daily report edits to flag claims for correction. Runs claims manually through McKesson Claim Check as needed
Audits and tests system configuration changes or new client implementations in the claims system timely
Reviews all daily supplemental audit reports and takes appropriate actions
Performs retrospective audits identifying overpayments, underpayments and system configuration issues
Minimum 5 years’ experience in professional and institutional healthcare claims examining and auditing
Minimum 2 years’ claims auditing experience
Strong knowledge and understanding of Managed Healthcare
Must be well versed in reading healthplan DOFRs and understand all types of fee schedules, including risk pools
Excellent knowledge of CPT, RBRVS, DRG, HCPCS and ICD-9 coding and regulations
Software: Microsoft Office, EZ-Cap, McKesson Claim Check, Redbook, DRG Pricing Software

Claims Auditor Resume Examples & Samples

Must possess strong research and problem solving skills
Requires a High School diploma or GED
5+ years of claims processing experience including a minimum of 1 year related experience in a quality audit capacity (preferably in healthcare or insurance sector) with consistent above target performance; working knowledge of insurance industry and medical terminology; detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines; and ability to acquire and perform progressively more complex skills and tasks in a production environment or any combination of education and experience which would provide an equivalent background

Senior Delegated Claims Auditor Resume Examples & Samples

Understanding of all aspect of the HMO and Delegated model
Recent experience utilizing Microsoft Word, Excel, Access and PowerPoint
Experience utilizing NICE and COSMOS Platforms
Bachelor's Degree (or higher)

Claims Auditor Resume Examples & Samples

Audit and tests payments for accuracy according to established guidelines and provides education/feedback as applicable
Traces sources of inaccuracies; reports and proposes remediation action to appropriate manager
Prepares and maintains detailed reports of audit findings and submits reports/findings as requested
Cross trained in all audits including high dollar claims audits and releases
Communicates results, reports and finding
Ensures safeguarding of assets through the verification of documentation, approvals and accurate coding of provider service and accounting data
Monitors and coordinates special transactions such as check adjustments and credits
Formats and prepares statistical reports and works close with CAD and local Finance Department to determine causes of errors and achieve corrective action
Performs special comprehensive audits as indicated or requested by management
Kaiser Permanente conducts compensation reviews of positions on a routine basis
At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees
Health care with two (2) years of auditing and medical billing experience
Bachelor's degree in accounting, audit, finance or management OR four (4) years of experience in a directly related field
Minimum five (5) years of claims knowledge
Bilingual Status (English, Spanish)
Minimum of 4 years experience auditing Medical Hospital and Professional Claims
Minimum of 5 years of ICD-9, ICD-10, and CPT Coding Experience
Knowledge of CMS Billing Guidelines, Payor Specific Guidelines, and Coding Guidelines
Must have excellent communication and analytical skills
Must have experience and proficient in Excel, Access, and Power-point programs

Claims Auditor Resume Examples & Samples

Professionally represent the ADMCRS brand, its teams, and uphold our Fundamental Principles and Code of Ethics
Nurture and ensure claims satisfaction and build loyalty, trust, and dependability through focused attention to our customers
Recommend alternative methodologies and processes that could reduce the frequency of common customer inquiries from re-occurring
Create and foster a team environment that encourages initiative, creativity, and solutions for overall company goal achievement
Consistently deliver punctual courteous service to all internal/external customers
Be available as needed and rapidly acknowledge communication transmissions (phone, email, text) received from customers
Apply critical thinking and problem-solving skills to resolve internal/external customer issues
Ability to locate and interpret policy/handbook language and apply it via application or give written/oral responses
Ability to read maps and aerial photographs
Must be able to make decisions using sound judgment
Ability to audit claims in a timely manner with tight deadlines
Willingness to use own initiative with minimal supervision
Ability to handle problem situations with internal/external customers in a professional manner
Be able to follow appropriate regulatory rules, regulations, and procedures
Other duties and responsibilities as designated and apportioned
A minimum of two (2) years’ experience employed with an AIP or Crop Insurance Agency
At least three (3) years’ experience in customer/client service, account management, or business development disciplines
Agricultural experience (e.g., farming, farming operations) desirable
Proficient in Microsoft Office applications and ability to learn new applications
Detailed Oriented
Excellent interpersonal, written, and verbal communication skills

Senior Claims Auditor Resume Examples & Samples

Participate in internal audits to ensure all claims are adjudicated in accordance with Plan, State and Federal regulations and adjudication logic. (This includes CMS and direct clients.)
Serves as the voice of Beacon Claims and Quality Control for external audits
Conducts claims investigations to insure proper billing practices from contracted and non-contracted providers
Participates in Fraud & Abuse committee meetings
Produces and maintains recurring reports that show Claims quality, both representing the overall Service Center and specific to our plan customers
Reviews results timely and come to independent conclusions that can be explained clearly and supported through data
Keeps management apprised of issues that may arise
Assist in training new staff

Claims Auditor Team Lead Resume Examples & Samples

Leads and monitors team of 6-12 Claims Auditors; may have some Claims Auditor duties in addition
Provides supervision and monitoring of Claims Auditors to ensure accuracy and consistency in auditing of claims
Supports daily operations of department by actively providing direction to the auditingteam
Trains and coaches Auditing staff
Acts as a liaison between management, auditing team, and external customers
Ensures projects are completed on schedule following established procedures and timelines
Assists management with maintaining data integrity and quality through regular quality assessments
Develops and maintains auditing team, collaborative relationships and communications with all levels of personnel
Assists management in research and reporting of data, as needed
Performs ongoing operational tasks for unit as needed
Reviews all audit types on projects
Serves as an expert resource on claims auditing
Claims Auditor duties: Tests payments for accuracy according to established guidelines and provides education/feedback as applicable
Traces sources of inaccuracies; reports and proposes remedial action to appropriate manager
Prepares detailed reports of audit findings and submits reports/findings as requested
Carries out and maintains records of special processing payment adjustments/checks requested
Works with Finance Department and others as resource regarding all aspects of Outside Medical Claims; researches and provides reports as requested
Reviews processing of outside medical payments on a continuous basis
Performs audit of data entered for outside medical payments for the purpose of performance feedback
Formats and prepares statistical reports and works close with CCA and local Finance Department to determine causes of errors and achieve corrective action
Ensures accurate recording of outside medical utilization data by testing for appropriate and consistent invoice coding
Minimum one (1) year of lead or supervisory experience required
Demonstrated expertise in audit processing, with minimum two (2) years of relevant auditing experience within the last five (5) years
Minimum two (2) years of experience working with CMS regulations and compliance regulatory requirements associated with external and referral claims
BA/BS degree in a relevant discipline such as health information management preferred
Bilingual English/Spanish preferred
Type 40 wpm preferred
5 years of Medical Coding ICD-9, ICD-10, CPT, and HCPCS preferred
5 years of experience working/auditing Medical Insurance Claim forms CMS-1500 UB04 preferred
At least 5 to 7 years of experience in individual and group supervision experience in the coding/billing and claims auditing field
5-7 years of experience of Medical Insurance authorization processing
Payroll processing experience preferred
High analytical and critical thinking skills preferred

Claims Auditor Specialist, Senior Resume Examples & Samples

Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer
Processes all types of medical claims and adjusts medical disputed claims (Professional and Facility) according to department, contract, and regulatory requirements
Performs prepayment audit on all types of medical claims (Professional and Facility) according to department, contract, and regulatory requirements
Answers telephone inquiries through the “Automated Call Distributor (ACD) Telephone System” as needed
Identifies individual provider needs and take appropriate steps to satisfy those needs
Updates authorization information based on information obtained from provider
Troubleshoots problem claims to resolve provider issues or systematic issues
Verifies and interprets information in all vendor contracts to resolve issues
Trains analysts and monitors general office support functions as needed
Analyzes work processes, identifies areas needing improvements and initiates necessary steps to make changes
Participates in the continuous quality improvement of IMCS core business system
Follows unit procedures for performing call processing, claim adjustments and denials and references Policies and Procedures, job aides, provider contracts, and other reference materials to assure complete and accurate decisions
Performs additional duties as assigned
Knowledge of Microsoft Office products
Individual must be reliable, dependable, and punctual
Excellent customer service and telephone skills
Ability to work in an environment with fluctuating workloads
Ability to solve problems systematically, using sound business judgment
Ability to make decisions with every call and handle escalated issues
Ability to make decisions regarding escalation of referrals to Care Management
Familiarity with ICD-9 and CPT codes
Knowledge of all types of professional claims
Ability to research and verify claims payment issues
Knowledge of compliance related to the processing of claims
Knowledge of medical terminology and pricing options
Knowledge of different sources of authorization documentation
Ability to update authorization information based on information obtained from facilities
Ability to read and interpret all vendor contracts
Knowledge of DRG pricing

Construction Claims Auditor Resume Examples & Samples

CPA is mandatory
Other certifications (CFE, CCP, CCIFP, etc.) helpful
Above average understanding of key cost accounting issues
Basic understanding of contract types, the construction process, and what can go wrong
Experience with construction change orders and claims
Experience with workpapers preparation
Ability to organize and write reports, including necessary support graphics or analyses that
Demonstrate opinions
Ability for 25% travel including a passport
Have or can obtain a US secret level security clearance
Ability to read and understand legal documents, contracts, pleadings, etc
Ability to plan and complete work on a time efficient basis

Delegated Claims Auditor Resume Examples & Samples

Performs oversight-monitoring activities including analysis of monthly reports, as well as conducting trending analysis and review of Monthly Timeliness Reports
Facilitates ad-hoc meeting with delegates to discuss and proactively address identified issues
Provides consistent updates and reporting to Manager, and other key stakeholders on an ongoing basis for all business process optimization needs
Performs oversight-monitoring activities for the delegates, including analysis of monthly reports, as well as conducting trending analysis and review of Monthly Timeliness Reports Facilitates ad-hoc meeting with delegates to discuss and proactively address identified issues. Provides consistent updates and reporting to Manager, and other key stakeholders on an ongoing basis for all business process optimization needs
5+ years of Claims Processing and Auditing experience for the following claim types: Inpatient/Outpatient, Ambulance, and Anesthesia
Recent experience utilizing Microsoft Word (creating/editing documents), Excel (Vlookup and formulas), and PowerPoint (how to create presentations)
Recent experience utilizing Microsoft Access (ability to modify any data within the database, produce reports from the database)

Senior Claims Auditor Resume Examples & Samples

Reviews benefit plans to ensure that claims are being adjudicated accurately and consistently according to Magellan contracts
Audit claims for statistical and financial accuracy
Responsible for documenting and reporting issues found
Assist with the establishment and updating of processes and audit manuals
Identifies areas where issues exist and works with appropriate individuals to ensure the resolution of the issues
Completes special focused audits as assigned by management
Train new auditors
Work with trainers to audit and develop trainees
Act as a resource for the auditing team
Assist and back-up to Lead Auditor

Claims Auditor Resume Examples & Samples

Reviews claims, as assigned, to ensure accuracy and compliance with established policies and procedures
Keep accurate records of audit results in audit database for individual and client reporting
Provides accuracy feedback to processors/examiners and claims management
Supports Management team as needed on audit related projects

Claims Auditor Resume Examples & Samples

Review daily reports summarizing internal certifications
Adjust certification errors as they are identified
Track trends identified in daily reports
Provide feedback on trends to Clinical Admin Director and Account Manager
Daily interaction with Regence BlueShield to identify and resolve certification errors
Performance of pre-review screening activities is limited to
Review of service requests (collection and transfer of non-clinical data, acquisition of structured clinical data and activities that do not include evaluation of interpretation of clinical information)
Sue of scripts and/or algorithms (approved by the Medical Director and Clinical manager no less than annually) to certify care
Health services that do not need medical necessity certification, result in a non-certification decision, nor require evaluation or interpretation of clinical information
One to two years working in healthcare or claims/customer service experience is required
Managed care background, claims background- research or customer service - is needed for this role
Communicate effectively and accurately
Handle multiple tasks while maintaining a high degree of accuracy
Perform duties in a timely manner
Maintains privacy and confidentiality
Work under pressure
Refer problems to appropriate personnel

HRA Claims Auditor Resume Examples & Samples

Audits Claims Analyst adjudication of claims against client specific plan rules and IRS 213(d) guidelines to ensure accurate and timely reimbursement
Assists HRA Claims Manager with internal and external audits
Tracks accuracy of Claims Analyst adjudication
Develop full understanding of new client HRA business rules and reimbursement requirements
High School diploma required. 4 year college degree preferred
1 year experience in customer service required. 2-3 preferred. Experience in retiree HRA industry highly preferred
Demonstrated mathematics skills
Must understand reimbursement rules for qualified health expenses
Excellent time management and organizational skills to handle multiple tasks and client projects
Strong problem solving skills to resolve customer service and departmental issues
Excellent written and verbal communication skills to effectively interact with internal and external customers
Highest level of attention to detail to ensure accuracy

Claims Auditor Resume Examples & Samples

Minimum 6 years’ experience as a Claims Analyst/Examiner in the healthcare industry or a Managed Care environment
Excellent organizational, time management skills and ability to multitask
Excellent analytical and problem solving skills
Proven knowledge of HMO insurance, Medicare, Medi-Cal and Covered California with emphasis on claims processing and enrollment
Proficient in medical terminology and the use of ICD-9/ICD-10, CPT, HCPCS and DRG’s
Proficient in reviewing Provider Dispute Resolution for accuracy and initiating refund requests as necessary
Knowledge of DOFR’s (Division Of Financial Risk), newborn guidelines and AB1455
Proficient in Excel, Word and Microsoft Office
Ability to work independently in research and decision making

Medicare Claims Auditor Resume Examples & Samples

Identify and quantify issues, as well as recommend new audit criteria
Assist with the identification of process improvement opportunities based on claims audit review
Participate on conference calls with managers/director to provide findings, as required
Preferred: Medical audit experience
Decision making ability that requires the use of considerable judgement in the analysis of data and the problems/errors resulting from the analysis
Possess strong organizational skills
Ability to perform multiple tasks
Communicate effectively, establish and maintain an effective working relationship within other areas of the organization

Claims Auditor Resume Examples & Samples

Responsible for pre and post payment and adjudication audits of high dollar claims across multiple lines of business, claim types and products including specialized claims within Service Experience
Works independently and without significant guidance
Primary duties may include, but are not limited to: Performs audits of and may adjudicate high dollar claims while maintaining acceptable levels of claims inventory and age
Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, system coding and pricing, pre-authorization, and medical necessity
Contacts others to obtain any necessary information
Completes and maintains detailed documentation of audit which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis
Provides feedback on claims processing errors; identifies quality improvement opportunities and initiates basic and complex system requests related to coding or system issues
Refers overpayment opportunities to Recovery Team. Independently interprets Medical Policy and Clinical Guidelines
5+ years of claims processing experience including a minimum of 1 year related experience in a quality audit capacity (preferably in healthcare or insurance sector) with consistent above target performance
Working knowledge of insurance industry and medical terminology
Detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines
Ability to acquire and perform progressively more complex skills and tasks in a production environment or any combination of education and experience which would provide an equivalent background

Claims Auditor Resume Examples & Samples

Completes special projects and other duties, as assigned
Must have regular and predictable attendance
Four (4) year college degree preferred. The college degree requirement will be waived for internal candidates with a minimum of 4 years claims experience and a score of 3.0 or higher on their last performance evaluation
A minimum of one (1) year claims handling experience
Internal candidate must have demonstrated high quality work and thorough knowledge of claims handling processes and state regulations and must have a score of 3.0 or higher on their last performance evaluation
Internal candidate must have successful completion of all required courses and satisfactory performance as an Initial Action Adjuster I or similar position
Ability to prepare and present reports documenting the results of audits
Strong analytical skills and detail orientated
Ability to handle sensitive information and maintain confidentiality
Working knowledge of Word and Excel and ability to perform Internet research

Senior Claims Auditor Resume Examples & Samples

Researches claim processing problems and errors to determine their origin and appropriate resolution. Prepare reports and summarizes observations for management summarizing observations and recommendations
Performs special project audits and reviews as requested by other departments / regions
Maintains a minimum audit accuracy rate
Regular and consistent attendance
High school diploma or a GED
3+ years Medical Claims experience
Experience working with Medicare / Medicaid / HMO
Knowledge of healthcare regulations and guidelines including CMS and MHC as pertains to AB1455. Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms, and CPT Coding
Associates Degree (AA) or 2-3 years related experience and/or training; or equivalent combination of education and experience
Intermediate skill levels in Microsoft Word, Excel, and Outlook
Ability to write routine reports and correspondence
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra
Ability to apply common sense understanding to carry out instructions furnished in written, oral, and diagram form

Claims Auditor Resume Examples & Samples

Commercial Casualty claims expertise in the South Central U.S
Commercial Casualty claims expertise in the Southeast
Multi-line adjusting experience with heavy Auto Physical Damage knowledge
Workers Compensation claims handling experience in the Northeast
Workers Compensation claims handling experience in California
Conducting timely and accurate audits of claims in various jurisdictions for adherence to company guidelines
Providing instructive and constructive feedback
Conducting and/or participating in field diagnostic events to promote calibration
Delivering timely formal written reports, maintaining production goals for the team
Serving as a technical resource/ Subject Matter Expert for the region where the auditor maintains residency
10+ years claims management experience in worker’s compensation, casualty, and/or APD. Multi-line experience preferred
Strong verbal, written and presentation skills
Ability to organize, prioritize and execute projects
Ability to deliver and accept constructive criticism/feedback
Maintain valid adjuster’s license in home state or in areas as jurisdictionally required
Ability to be flexible and creative

Claims Auditor Resume Examples & Samples

2) EXCELLENT written & verbal communication skills
3) GREAT organizational skills
4) Research claims
5) Request information from internal or external sources
6) Basic knowledge of Microsoft office & Excel

Claims Auditor, Snr Resume Examples & Samples

Data analysis on current reports (error reports, review trend analysis reports for accuracy, etc.). Provide analysis on errors identified in the OPA, SOX & AON audits by determining the root cause for each error reported
Supervise&distribute the QC tool work w/ QA Supervisor. Prepare&distribute reports to Mgmt, HPRS, NCO&Internal Audit staff
Run the unassigned inventory reports from the QC tool weekly & distribute the audits to the Auditors in Oakl& & Walnut Creek. Redistribute work in the QC Tool as needed. Provide CCA Compliance, QA & Operations Mgmt w/ Outstanding audits, Denial, OPA accuracy, overpayment & underpayment reports throughout the month
Prepare & conduct OJT schedule
This job is the fully-qualified, career-oriented, journey-level position
Awareness of work required at next level & working at that standard. Provide feedback to the operations team, & auditors on the identified factors
Minimum three (3) years of claims auditing experience
N/A

Claims Auditor Resume Examples & Samples

Gather information to review, analyze and accurately audit claims
Reviews claims (CMS 1500 and UB04) for accuracy of claim determination following CMS criteria
Performs routine and moderately complex audits on individual, random and focused claims to identify exceptions to established claims adjudication requirements
Communicates to the department when a problem has been identified
Works as a team player and communicates in a positive manner with members, providers, co-workers, managers and other contacts
Effectively develops organizational capabilities
Prepares and distributes reports, summarizes findings and recommendations
Prioritizes and manages individual workflow as needed
Claims auditor performs pre-payment and retrospective audits to verify the payment accurately reflects the contracts while meeting or exceeding individual accuracy, production and timely auditing objectives
Must cross-train in the auditing of all networks
Performs all other duties may be assigned as needed
3 years experience in medical/institutional claims processing within an IPA/Medical Group setting
Familiarity with computerized claims processing/transaction system and medical code (CPT and ICD9/ICD10)
Familiarity with medical/hospital coding (CPT, ICD-9/ICD-10, ASA) and standard billing formats (CMS 1500, UB04). Comprehensive knowledge of claims reimbursement methodology
Be able to work effectively under pressure
Possess strong analytical and problem solving skills
Requires good written and verbal communication skills to communicate effectively
Possess a high level of flexibility and attention to detail
Must be able to work as a team player and have a professional demeanor

Senior External Claims Auditor Resume Examples & Samples

Bachelor’s degree in Business Administration, Health Care Administration, Health Policy or Finance
Three years’ experience with health insurance operational or compliance audits or related experience in the healthcare or financial services industry
Strong knowledge of health insurance industry lines of business, product lines, systems, policies, procedures, flows and interdepartmental relationships and impacts
Strong claims auditing skills and ability to interpret data to formulate a position / response to an audit finding
Ability to communicate effectively in writing using common business language in a healthcare setting
Advanced Microsoft Office and claims processing systems skills

Delegated Claims Auditor Resume Examples & Samples

Exhibits each of the Mount Carmel Service Excellence Behavior Standards holding self and others accountable and role modeling excellence for all to see. For example: demonstrates friendliness and courtesy, effective communication creates a professional environment and provides first class service
Meets population specific and all other competencies according to department requirements
Promotes a Culture of Safety by adhering to policy, procedures and plans that are in place to prevent workplace injury, violence or adverse outcome to associates and patients
Relationship-based Care: Creates a caring and healing environment that keeps the patient and family at the center of care throughout their experience at Mount Carmel following the principles of our interdisciplinary care delivery system
(For patient care providers) Provides nursing care, ensures an environment of patient safety, promotes evidence-based practice and quality initiatives and exhibits professionalism in nursing practice within the model of the ANCC Magnet Recognition Program®
Responsible for performing weekly audits of the claims processing delegated vendor including financial accuracy, data entry accuracy, timeliness and procedural accuracy
Responsible for working with the delegated vendor to identify issues and appropriate resolution to any items revealed through the audit process
Compiles and maintains audit statistics and trends to be reported to the Claims Director, Chief Operating Officer and the Controller
Identify trends and report findings promptly to Claims Director
Represent Claims Department on the Delegated Oversight Committee and Fraud, Waste and Abuse Committee, as appropriate
Attend Joint Operating Committee meetings with all delegated vendors
Function as a resource for the auditing and testing of system set up for new clients and
Newly contracted providers
Responds to both external provider and internal requests for review of adjudicated claims
Maintains a current knowledge of Medicare and Medicare Advantage activities through monitoring of websites, newsletters, trade groups and attending workshops, as available
Acts as a resource to Finance regarding all aspects of delegated claims processing
Ensure safeguarding of assets through verification of documentation, approvals, and accurate coding of billed provider services
Assist Quality Management, Finance and Plan in preparation for internal and external audits
Maintain a current knowledge of the claims operating system
Responsible for compliance with Organizational Integrity through raising questions and promptly reporting actual or potential wrongdoing
Education: High school graduate required. Associate Degree or some college preferred
Licensure / Certification: Certified Professional Coder preferred
Experience: Minimum three (3) to five (5) years of progressive claims experience
Effective Communication Skills
Demonstrates knowledge of claims processing and managed care operations including a thorough understanding of auditing processes, procedures and standards, a thorough understanding of current medical terminology and coding through the use of CPT, ICD9, HCPCs and DSMIV, strong analytical skills to evaluate, monitor and measure ongoing trends, demonstrated decision-making and problem-solving skills, strong organizational skills to effectively manage multiple priorities simultaneously and successfully and strong computer skills along with claims and business systems