Claims Audit Specialist I

Job Opportunity At PacificSource

Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Perform claim audits and report on results to identify training needs and system or process issues. Research policy, network, contract reimbursement and claims processing guidelines to determine accuracy of processing. Accurately interpret benefit and policy provisions applicable to fully-insured group / individuals and self-funded clients. Reprocess claims due to processing errors, setup / system errors, eligibility updates and other retro changes. Review corrected claims from providers and facilities to determine if they meet standards for required documentation, content, and timeliness and reprocess or communicate denial as necessary. Responsible for identifying overpayments, preparing recovery requests, and performing follow-up tasks on outstanding overpayments. Provide customer service to internal and external customers regarding overpayment transactions. Provide support to internal staff regarding claims processing rules and procedures.

Essential Responsibilities :

• Perform random and problem-focused audits of claims by researching benefits, reimbursement contracts, claim edits and claim policies and procedures, comparing to the processed claim. Provide immediate feedback on claims with errors to claims analysts and team leaders.
• Review claims, verifying accuracy of data entry including patient information, procedure and diagnosis codes, amount(s) billed, and provider data. Review plan benefits and determine coverage based on contract and claims processing guidelines.
• Accurately resolve or reprocess claims to correct processing, setup and / or system errors identified through multiple channels according to the instructions provided for the project. Evaluate claims reprocessing requests to determine compliance with claims reprocessing standards prior to adjusting claims.
• Accurately resolve or reprocess claims due to updated eligibility, benefits or provider status.
• Review corrected claims / rebills from providers and facilities and determine if the request meets standards for required documentation and timeliness. Review chart notes, claim itemization and other documentation. Reprocess claim(s) if rebill meets standards for adjustment. Communicate denial if the rebill does not meet standards and / or requires additional documentation.
• Work assigned reports to monitor and / or correct claims for specific processing reasons. Assist in processing other specialty claims / projects as workload or auditing requires.
• Identify overpayments and prepare recovery requests. Follow up with both members and providers on outstanding overpayments. Research, reconcile and post refunds against affected claims.
• Provide service to internal and external customers via customer service tasks, audit email queue, and phone etc. to reprocess claims, answer questions and resolve refund issues.
• Document issues that affect other PacificSource departments and advise appropriate internal personnel of claims processing concerns and / or problems. Use established communication channels to notify internal departments and personnel.
• Document issues that affect claims processing quality and advise team leaders of claims processing or system configuration concerns and / or problems.
• Provide support to department staff and internal customers to answer questions regarding claims processing rules and processes. Provide support to internal and external customers regarding overpayment transactions.
• Assist in claim grievance and appeal research and resolution.
• Develop and maintain positive relationships with outside vendors that contract with PacificSource for claims related services. May communicate via phone, email, or business letter.
• Develop training materials and deliver one-on-one or group training to other claims analysts using Lean training techniques as assigned.

Supporting Responsibilities :

Work Experience :

Minimum of two years claims experience in healthcare or health insurance with preference for claims adjudication experience.

Education, Certificates, Licenses :

Requires high school diploma or equivalent.

Knowledge :

Thorough understanding of PacificSource products, plan designs, provider / network relationships and health insurance terminology. Research skills and ability to evaluate claims in order to enter and process accurately. Computer skills including keyboarding and 10-key proficiency, basic Microsoft Word and Excel. Ability to prioritize work and perform under time constraints with minimal direct supervision. Ability to communicate effectively with all types of customers. Ability to develop Lean training materials and deliver claims training to others. A fundamental understanding of self-insured business is helpful.

Competencies : Adaptability

Building Customer Loyalty

Building Strategic Work Relationships

Building Trust

Continuous Improvement

Contributing to Team Success

Planning and Organizing

Work Standards

Environment :

Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Skills :

Accountability, Collaboration, Communication (written / verbal), Flexibility, Listening (active), Organizational skills / Planning and Organization, Problem Solving, Teamwork

Our Values :

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business :

Physical Requirements :

Stoop and bend. Sit and / or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer : This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.