Career Center

The Claims Auditor performs claims audits based on the audit program and specified target audits as assigned.

• Responsible for ensuring the accuracy of claims payments with the application of managed care contracts, as well as reimbursement calculation of applicable fee schedules for non-contracted claims. 
• Identifies underpayments/overpayments and generates periodic reports to quantify amounts detected through the audit process.
• Communicates errors to Compliance Manager and trends errors for corrective actions.
• Audits member liability denials to assure quality of claim determinations and ensures compliance with health plan, DMHC, and CMS requirements.
• Audits PDR and adjustments to assure the quality of the letters generated, the accuracy of the data loaded into the Provider Dispute database, and the accuracy of the determination or adjustment.
• Performs other duties as assigned.