Ultimate Staffing | Medical Claims Examiner/Auditor

We are seeking a Claims Auditor to join our team! Reporting to the Administrative Manager and taking direction from the Claims Manager, the Claims Auditor will ensure accurate claims processing, compliance with regulations, and fraud prevention. This role is integral in maintaining the quality and efficiency of our claims operations.Key ResponsibilitiesReview processed claims for payment accuracy and compliance with regulations.Conduct daily, focus, and random audits of claims and providermember calls.Identify and correct claims adjudication errors, ensuring accuracy pre- and post-payment.Monitor claims for potential fraud, waste, and abuse.Generate and analyze reports to resolve held and prepayment audits.Maintain and update the Claims Manual Processing Guide.Provide productivity and audit reports to the Claims municate process improvement suggestions to enhance departmental efficiency.QualificationsHigh School diplomaGED required; Associate's degree preferred.2+ years of experience in health claims auditing (5+ years desired).Strong knowledge of ICD-10, CPT, HCPCS codes, and healthcare billing procedures.Proficiency in Microsoft Word, Excel, and proprietary software applications.Exceptional organizational, multitasking, and time management skills.Clear and professional communication skills, both written and verbal.Ability to work independently and collaboratively in a team environment.All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance. For unincorporated Los Angeles county, to the extent our customers require a background check for certain positions, the Company faces a significant risk to its business operations and business reputation unless a review of criminal history is conducted for those specific job positions.

Created: 2025-01-19