Managed Care Claims Auditor

Description Hourly Wage Estimate: 33.18 - 48.13 / hour Learn more about the benefits offered for this job. The estimate displayed represents the typical wage range of candidates hired. Factors that may be used to determine your actual salary may include your specific skills, how many years of experience you have and comparison to other employees already in this role. The typical candidate is hired below midpoint of the range. • *Must reside in the San Jose, CA Bay area** Introduction Are you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family! Jump-start your career as a Managed Care Claims Auditor today with Work from Home. Benefits Work from Home offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: • Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. • Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. • Free counseling services and resources for emotional, physical and financial wellbeing • 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) • Employee Stock Purchase Plan with 10% off HCA Healthcare stock • Family support through fertility and family building benefits with Progyny and adoption assistance. • Referral services for child, elder and pet care, home and auto repair, event planning and more • Consumer discounts through Abenity and Consumer Discounts • Retirement readiness, rollover assistance services and preferred banking partnerships • Education assistance (tuition, student loan, certification support, dependent scholarships) • Colleague recognition program • Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) • Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. Come join our team as a Managed Care Claims Auditor. We care for our community! Just last year, HCA Healthcare and our colleagues donated 13.8 million dollars to charitable organizations. Apply Today! Job Summary and Qualifications The Auditor primary function is to ensure examiner payment accuracy of all claims processing including analysis of support services fulfillment colleagues' workflow and activities. Provide feedback to examiner(s) and support services personnel and conduct additional training, based on audit findings. DUTIES INCLUDE BUT NOT LIMITED TO: • Perform concurrent and retrospective review of paper & electronic claims processed and office services fulfillment team Optical Character Recognition (OCR), clearinghouse and mail interface vendor activities' performance at all levels. • Review routine random sampling audit of examiner processed claim(s) for accuracy and provides feedback to the examiner. • Review support team workflows to ensure regulatory timeliness, distribution and accuracy guidelines are met. • Report metric volume, procedural and financial accuracy on a recurring schedule to claim management. • Identify root cause of system and/or examiner errors, report to claim leadership for appropriate corrective action. • Partner with claim management on performance management recommendation. • Weekly review of high-dollar claims. • Review and analyze audit data, including trend results with recommendation of process changes, refresher training and system enhancements to improve systemic examiner and system quality/performance. • Maintain working knowledge of department policies and procedures for use in standard audit workflows in claim & support departments. • Perform focus audit as necessary. • Perform other duties as assigned, including but limited to, processing of claims, PDR, adjustments, overpayments, etc. KNOWLEDGE, SKILLS AND ABILITIES MINIMUM REQUIREMENTS: • Subject Matter Expert (SME) in medical claims processing at health plan payor, Managed Services Organization (MSO), Health Maintenance Organization (HMO) and/or Independent Practice Association (IPA) organization • Hands-on knowledge and functional understanding of medical claims billing, processing, terminology, diagnosis and procedures. • Working knowledge of Commercial, Medicare and HMO lines of business processes • Ability to effectively review, interpret and apply Division of Financial Responsibility (DOFR) requirements. • Personal laptop and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, PowerPoint. • Technical proficiency in database and worksheet program applications. • Identify ICD-10, CPT-4, HCPCS, Revenue Codes, UB-04 and CMS-1500 forms • Work cooperatively and interact with auditors, examiners, support team and management positively. Adapt to changes in requirements/priorities on a daily basis. • Produce logs and reports as required. • Effectively communicate orally and in writing. • Analyze and evaluate information in an accurate manner. • Interpret policies & procedures. • Work independently using sound judgement in ambiguous and defined concepts. • Exercise outstanding time management capabilities. • Accept accountability of all tasks and results. EDUCATION: • High School Diploma required. College degree preferred. EXPERIENCE: • 4 - 5 years' experience as a Senior claim examiner in a managed care environment required • Customer service skills required • Prior medical claim auditing experience preferred Physician Services Group is skilled in physician employment, practice and urgent care operations. We are experts in hospitalist integration, and graduate medical education. We lead more than 1,300 physician practices and 170+ urgent care centers. We are HCA Healthcare's graduate medical education leader. We provide direction for over 260 exceptional resident and fellowship programs. We focus on carrying out value-added solutions. These solutions help physicians deliver patient-centered healthcare. We support HCA Healthcares commitment to the care and improvement of human life. HCA Healthcare has been recognized as one of the World's Most Ethical Companies by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. "The great hospitals will always put the patient and the patients family first, and the really great institutions will provide care with warmth, compassion, and dignity for the individual."- Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our Claims Auditor opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and apply today! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status. Employment Type: Full-time Apply tot his job