Claims Auditor- Full Time

Responsibilities

Come and join the RMC Family!

We have been in the community since 1935. Our mission is to provide comprehensive multi-specialty medical services in the greater Riverside region.

Your passion, inspiration, and talents are invaluable to us and our mission to serve others. Our facility can provide a place for you to thrive and continue your professional development. Quality Healthcare is our passion, improving lives is our reward. We are working to change lives and transform the delivery of healthcare.

Riverside Medical Clinic is the best place to work, practice medicine, and receive care.

SUMMARY: Responsible for auditing and training claims staff on all Managed Care claims received from outside providers to ensure the Claims Examiners processed and adjudicated them accurately and consistently in accordance with outside Provider Contracts, State, Federal, CMS, DMHC and Health Plan contracts, internal departmental policies and procedures. Must maintain a productivity standard of auditing 15 claims per hour.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.

The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Some knowledge of Microsoft Word, Excel and Access database software programs is required.

HOURS: Monday-Friday 7:30AM-4:00PM

Qualifications

EDUCATION and/or EXPERIENCE: High school diploma or general education degree (GED); or Four (4) or more years with claims processing experience and/or training; or equivalent combination of education and experience. Must possess a strong knowledge of the Centers for Medicare and Medicaid Services (CMS), the Department of Managed Health Care (DMHC) and HMO standards and requirements.

CERTIFICATES, LICENSES, AND REGISTRATIONS: None.

ESSENTIAL FUNCTIONS:

Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job's purpose and objectives. Essential functions are critical or fundamental to the performance of the job.

They are the major functions for which the person in the job is held accountable. Note: (other duties may be assigned, deleted or changed at any time, at the discretion of management, formally, or informally, either verbally or in writing).

1.Audit the Claim Examiners' batches daily, to ensure all claims were adjudicated in accordance with RMC Provider, HMO contracts, CPT rules for Correct Coding, DMHC, and CMS guidelines and requirements.

2.Daily track and report both financial and clerical claims processing errors in the auditor Access database program, and report all findings to the Manager.

3.Assist the Claims Examiners and other personnel with claims, contract interpretation, and coding issues. Notifies them in writing when any changes to procedure occur.

4.Regular training of all Claims Examiners, through individual or group sessions, based on most common errors found during the audit process. Will supply materials and necessary documentation to claims examiners, and provide backup to the Claims Supervisor.

5.Assist the Claims Supervisor with processing claims when inventory begins to rise or needed.

6.Responsible for ensuring batch corrections are completed and returned in a timely manner to meet the weekly Friday provider check run deadline. Follow-up with the Claims Supervisor as necessary when batches are not returned on time.

7.To ensure the batch is logged in the Batch Control section of the Auditor database, communicate to the appropriate Customer Service staff when all batch corrections have been completed to assure compliance with the Friday check run deadline.

8.Review the drawers of claims processed to ensure that Customer Service has filed the claims accurately in "To-Pay" date order. Notify Management of any discrepancies found.

9.Attend applicable meetings to ensure all claims adjudication issues are effectively addressed and corrections are completed in a timely and accurate manner.

10. Other duties as assigned by Management.

This opportunity offers the following:

Challenging and rewarding work environment

Growth and Development Opportunities within UHS and its Subsidiaries

Competitive Compensation

About Universal Health Services

One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World's Most Admired Companies by Fortune; and listed in Forbes ranking of America's Largest Public Companies.

Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

Avoid and Report Recruitment Scams

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.