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Claims Auditor

Send to my Email Email a friend Job ID 75203 Date posted 08/03/2016
Requisition ID: 75203
  • Facility: Sharp HealthPlan
  • City: San Diego
  • Department: Finance
  • Category: Business Operations Jobs
  • Job Status: Full-Time
  • Shift: Day Job
  • FTE: 1.0
  • Shift Start: 8 AM
  • Shift End Time: 5 PM
Location
This position is located in Kearny Mesa, San Diego County. 
 
Hours
8-hour shift: 8:00 am – 5:00 pm, Weekends as needed.
 
Required Skills and Qualifications
  • High School Diploma required
  • 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.
  • Ability to work independently.
  • 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.
  • Excellent verbal and written communication skills.
  • Proficient in Excel, Word and Microsoft Office.
  • Ability to work independently in research and decision making.
 

Summary
This position will be responsible for researching and resolving complex health plan issues such as provider dispute resolutions, high dollar claims and refunds. Forwards claim issue to the appropriate unit/person for rework when necessary and documents all actions accordingly. Work in direct collaboration with the Claims Manager and Claims Lead on recommendations for improved contract set-up or claims adjudication policies. Will review claims processed prior to the scheduled weekly check runs to ensure accuracy of processing. Will track and trend issues on a weekly/monthly basis.
Sharp Health Plan is the largest locally based commercial health plan in San Diego. We are a not-for-profit health plan that has been serving San Diego and southern Riverside Counties since 1992. As a subsidiary of Sharp HealthCare, we are backed by the largest provider of comprehensive health care services in San Diego.
Sharp Health Plan offers a variety of coverage options that combine affordability and choice, while delivering high quality health care and personal service. We provide health insurance for companies of all sizes throughout the region. Members have access to valuable plan enhancements, such as interactive wellness resources, dental discounts and our exclusive global emergency services program. 
Essential Physical Requirements may include
  • Sitting
  • Keyboarding
  • Mousing
  • Lift up to 10 pounds
  • Push/pull up to 10 pounds
  • Carry up to 10 pounds
Additional physical requirements of position may be discussed during interview.
Sharp HealthCare is proud to be an Equal Opportunity/Affirmative Action Employer.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, gender identity, transgender status, sexual orientation, protected veteran status or any other protected class.
Keywords: Claims, Auditor, Certified Professional Coder, Coder
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