About this role
Job Title: Senior Claims Auditor Department: Ops - Claims Ops About the Role: We are currently seeking a highly motivated Senior Claims Auditor. This role will report to the Director - Claims and enable us to continue to scale in the healthcare industry. Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor are present at the time of audit Requires the ability to communicate and analyze claims processing methodologies according to CMS and DMHC guidelines Respond to preliminary results by the due dates Requires the ability to respond to the corrective action plan timely and address the root cause appropriately as well as remediate the deficiency Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows Handle complex and urgent audit projects from external provider and internal departments Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests Audit Documentation/Reconciliation Accurately document the underpayments and overpayments into the audit database Assist management with analyzing Claim error trends Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer Collaboration Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/ Finance, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution Identify training needs/ gaps for the team and ensure timely and effective training is imparted to all team members