Company: Bright Health
Location: Diamond Bar
Posted on: November 20, 2022
Supports the overall 100% quality effectiveness to ensure that all
claims are processed accurately and complete to insure appropriate
adjustment code usage, and payment rate.
Duties and Responsibilities
- Proficient with Federal and State requirements in claims
- Proficient understanding of AB1455 Claims Settlement Practice &
Dispute and Resolution regulations.
- Proficient in rate application for all CMS 1500 claims for all
lines of business. (Medicare, Commercial, Medi-Cal, & Healthy
- Proficient in rate application for all outpatient & inpatient
facility, ASC, Interim rate and CMAC rates of payment methods to
applicable lines of business. (Medicare, Commercial, Medi-Cal, and
- Must be able to verify that claims are paid in accordance with
correct contractual provision regulatory guidelines and all company
and departmental policies and procedures.
- Must be able to work independently and successfully with
- Must be able to work with Claims Examiners, give direction and
answer claims related questions to improve overall quality of the
department, and individual examiners.
- Performs "pre" and "post" audits for all department examiners,
at all levels.
- Ability to take verbal as well as written direction from Claims
- Can effectively use "Crystal reports" to capture deficiencies
in processed claims prior to check run.
- Run valid reports and provide monthly reporting to Claims
Operations Supervisor of claims examiner's quality.
- Must keep individual Claims Examiner results at a confidential
level between Auditor, Claims Examiner, and Claims Operation
Supervisor. Results are not discussed with other
- Makes recommendations to improve audit procedures and
consistency throughout the team.
- Familiarize and comply with claims timeliness guidelines:
Commercial claims 45 working days; Medi-Cal claims 30 calendar
days; Medicare non-contracted claims 30 calendar days; Medicare
contracted claims 60 calendar days.
- Proficient in, the application of "Coordination of
- Proficient in, and knows how to use and apply Health Plan
Benefit Matrices and Division of Financial Responsibility.
- Complies with all Company and Department Policies and
- Assist and resolve any grievances that the Claims Call Center
needs assistance on.
- Prompt and accurate response to claims related questions from
Supervisors, and Mgmt.
- Identify claims that fall under Third Party Liability
- Identify claims that are potential Stop Loss Case.
- Must havethree years of claims processing and or auditing
- Internal/external audit experience is preferred
- Must have the ability to work effectively with minimal
- Proficient in medical terminology, CPT, ICD9, Revenue codes,
- Excellent verbal and written communication skills.
- Excellent organizational skills and interpersonal
- Experience with EZ-CAP system claims module.
Keywords: Bright Health, Diamond Bar , Claims Auditor, Accounting, Auditing , Diamond Bar, California
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