Quality Control Claims Auditor

Company: Community Care Plan
Location: Fort Lauderdale
Posted on: August 2, 2022

Job Description:

**MUST BE WILLING TO PHYSICALLY WORK NEAR SUNRISE, FLORIDA, 33323**Position Summary:Monitors claims payments and conducts audits to provide investigative support related to potential fraud, waste, abuse and/or overpayment. Performs pre and post payment audits. Conduct medical record reviews for appropriate service documentation as per coding guidelines and medical necessity documentation as per clinical guidelines.Qualifications: Bachelor's Degree and/or four to six years related experience and/or training or equivalent combination of education and experience.Prior experience in claims auditor job role is required.Certified Professional Coder; CPC or CPC-H certification. (required)Certified Professional Medical Auditor (CPMA); Certified Medical Auditor Reimbursement Specialist (CMARS); Certified Medical Audit Specialist (CMAS); Certified Healthcare Chart Auditor (CHCA), and/or any equivalent thereof.Knowledge of Health Information Portability and Accountability Act (HIPAA) compliance.Knowledge of Medicaid rules, claims processing, medical terminology and coding principles and practices.Knowledge of auditing, investigation, and research.Knowledge of word processing software, spreadsheet software, payroll systems, and internet software.Essential Duties and Responsibilities:Performs audits of claims payments to identify potential fraud, waste, abuse and/or overpayment.Monitors claims payment accuracy by verifying various aspects of the claim including eligibility, system coding and pricing, pre-authorization, and medical necessity.Completes and maintains detailed documentation of audits including but not limited to coding guidelines reviewed, medical necessity documentation, decision methodology, and monetary discrepancies identified.Provides feedback on errors identified in the audit process; identifies quality improvement opportunities and initiates remediation efforts when potential fraud, waste, abuse and/or overpayment are identified.Coordinates overpayment recoveries with the SIU Manager.Responsible for pre and post payment claim auditing of medical records and associated clinical documentation to ensure proper billing in accordance with standard billing policies and reimbursement principles.Responsible for assisting the SIU Manager with potential fraud, waste or abuse investigations requiring medical coding expertise, participating in external audit requests, and special projects as needed.Coordinates, conducts, and documents audits as needed for investigative purposes.Prepares written reports or trending data related to findings and facilitates timely turnaround of audit results.Prepares written summaries of audit results for purposes of reporting potential fraud, waste, abuse and/or overpayment. Makes recommendations for improvement of procedures, documentation, and revenue optimization opportunities.Retrieves and compiles data across multiple information systems and provides needed information for internal and external customers in a timely manner.Recommends and assists in audit and documentation policy changes/new policies as necessary to ensure compliance, accurate billing, and sufficient documentation.Identifies potential provider fraud through review of claims data, complaint referrals, and application of rules, healthcare coding practices, and fraud detection software. Reviews provider billing practices to investigate claims data and compliance with State and Federal laws.Analyzes provider data and identifies erroneous or questionable billing practices.Interprets state and federal policies, Florida Medicaid, and contract requirements.Determines and calculates overpayment/underpayment and collects overpayment.Shares information with staff and providers regarding rules, regulations, and Medicaid Program Manual Guidelines.Communicates with fiscal staff to identify system errors or other issues.This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.Skills and Abilities:Excellent written and verbal communication skills.Ability to provide presentations to small groups.Ability to perform math calculations.Analytical and critical thinking skills.Ability to operate personal computer and general office equipment as necessary to complete essential functions, including using spreadsheets, word processing, database, email, internet, and other computer programs. Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.Ability to write reports, business correspondence, and procedure manuals.Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.WORK SCHEDULE:As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week. The company reserves the right to change the work schedules based on the company needs.Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

Keywords: Community Care Plan, Fort Lauderdale , Quality Control Claims Auditor, Accounting, Auditing , Fort Lauderdale, Florida