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Claims Auditor

Company: Bright Health
Location: Diamond Bar
Posted on: November 20, 2022

Job Description:

General Purpose
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 processing.
  • 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 Families).
  • 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 Healthy Families).
  • 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 limited supervision.
  • 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 Operation Supervisor.
  • 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 examiners.
  • 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 Benefits".
  • 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 Procedures.
  • 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 (TPL).
  • Identify claims that are potential Stop Loss Case.


    • Must havethree years of claims processing and or auditing experience.
    • Internal/external audit experience is preferred
    • Must have the ability to work effectively with minimal supervision.
    • Proficient in medical terminology, CPT, ICD9, Revenue codes, HCPCS codes
    • Excellent verbal and written communication skills.
    • Excellent organizational skills and interpersonal skills.
    • Experience with EZ-CAP system claims module.

Keywords: Bright Health, Diamond Bar , Claims Auditor, Accounting, Auditing , Diamond Bar, California

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