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Medical Claims Audit Analyst

Job ID 85287 Date posted 01/10/2018
  • Facility: Sharp HealthCare
  • City: San Diego
  • Department: PFS Claims Processing
  • Category: Business Operations Jobs
  • Job Status: Full-Time
  • Shift: Day Job
  • FTE: 1.0
  • Shift Start: 8 AM
  • Shift End Time: 4:30 PM
This position is located in Kearny Mesa, San Diego County.
Full time: 8am to 4:30pm.
Required Skills and Qualifications
  • Knowledge of health insurance or HMO operations with emphasis on claims processing, system set up and auditing software.
  • Ability to positively communicate with coworkers.
  • Excellent organizational and interpersonal skills.
  • Ability to work effectively as a member of a creative management team.
  • Excellent understanding of claims adjudication policies and procedures.
  • Adept in working with ClaimCheck editing software for accuracy and doing detailed claims reviews.
  • Excellent analytical skills and understanding impacts of changes in procedures on accuracy of adjudication.
  • A minimum of 5 years in HMO or medical claims auditing.
  • Proficient in GE, Microsoft Excel, and Microsoft Word.
  • Research skills and experience producing summaries and recommendations.
  • Must have strong written and verbal communication skills.
  • AAPC Certified Professional Coder (CPC) required.
Preferred Skills and Qualifications
  • Knowledge of word processing and spreadsheet applications is strongly preferred.
  • Experience in claims, customer service, and training preferred.


The Medical Claims Audit Analyst is in direct collaboration with the Sr. Medical Claims Audit Specialist and department management is responsible for auditing system claims edits, responding to claim audit questions, review of medical records and apply appropriate system edits as outlined by
our claims editing software. This includes but is not limited to the following functional areas: Claims Processing for Sharp Rees-Stealy, and Sharp Community Medical Group. This position is responsible for processing and reporting for a medical claim edit program. The position also supplies feedback on our systems to improve accuracy, timeliness, and efficiency of the department.
Department is comprised of 5 claims processing units that process HMO claims for 3 medical groups and Sharp Health Plan.
Sharp System Services have campuses located in the communities of Kearny Mesa and Serra Mesa and consist of the Spectrum location, the Ruffin Road location and Sharp Operations Center (SOC).  These offices provide the centralized integrated system support services to the operating entities within the system.  These services include: Strategic Planning, Business Development, Information Technology, Compliance, Internal Audit, Legal, Risk Management and Insurance, Contracts, Human Resources, Facilities Management and Development, Clinical Effectiveness, Finance, Nursing, Systems Supply Chain Services, Marketing and Communications, The Sharp Experience and Sharp University.
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: Medical Claims Audit Analyst

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