Claims Auditor in Pasadena, California at Imperial Management Administrators Services Inc

JOB DESCRIPTION

JOB TITLE: Claims Auditor FLSA STATUS: Non-Exempt

DEPARTMENT: Claims Audit

REPORTS TO: Claims Audit Manager / Claims Director

JOB SUMMARY:

The Claims Auditor is responsible for reviewing and auditing claims adjudicated by the system and claims examiners prior to check runs. This role ensures accuracy, identifies errors, verifies compliance with regulatory requirements, and provides recommendations for process and system improvements. The Claims Auditor also supports cross-departmental initiatives to maintain payment integrity and compliance with CMS, Medi-Cal, and commercial guidelines.

ESSENTIAL JOB FUNCTIONS:

Accurately apply Health Plan Benefit Matrices and DOFR (Division of Financial Responsibility) during audits.Facilitate corrections of claim adjudication errors and recommend process improvements. Test and audit new releases of Medicare and Medi-Cal Fee Schedules, and provider payment methodologies based on contract agreements. Maintain a strong understanding of provider contracting arrangements and benefits administration to support accurate and timely claim payments. Stay current on ICD-10, CPT, HCPCS, Revenue Codes, DRG, and billing procedures for healthcare providers and facilities, as well as Medicare and Medi-Cal reimbursement guidelines. Test and audit claim payments for accuracy against contract data in E-CAP. Generate and analyze audit reports to identify adjudication errors, overpayments, and underpayments.Document audit findings with detailed review process, justification, and conclusions.Track and analyze errors to identify trends and recommend training or system enhancements.Provide training and mentoring for new staff to improve accuracy and productivity.Maintain detailed knowledge of EZ-CAP rules related to claims payment.Ensure compliance with claim timeliness standards: