Claims Auditor, Perform quality review on claims, enrollment, and member service personnel on select criteria determined by management. Perform audits on personnel daily of randomly selected output, and complete appropriate forms for manager/supervisor feedback. Work closely with trainers on training needs identified through the quality review process. Answer questions for claims, enrollment and member service personnel. Establish training needs for employees identified during the quality review process.
- Claims Auditor at COMMUNITYCARE
- Refund Specialist and Claims Payable Specialist at COMMUNITYCARE
- at Financial Suspense Systems, BLUECROSS BLUESHIELD
- Bluecard Home/Host Claims Examiner at Financial Suspense Systems, BLUECROSS BLUESHIELD
1 year, 4 months at this Job
• Conduct audits of all type of claims.
• Document audit findings to prepare and submit various claims reports weekly and monthly for use by the Claims Department.
• Assist with on-site audits, to include interaction with outside vendors, researching claims questions, and providing requested and appropriate documentation.
• Maintain current and accurate records of all relevant communications, audits, corrective action plans, and effectiveness monitoring.
• Identify contractual discrepancies and communicate with Team Lead or Manager to ensure any questions are quickly resolved.
• Present the Claims Management team with feedback to evaluate staff and team quality and assists in identification of additional training needs using the audit results.
- Claims Auditor at Claims Department
- Lead Claims Auditor at Mirra Health Care
- Claims Trainer Coordinator at Training Department standards
- Quality Control Auditor at AvMed
7 months at this Job
- Master Degree in Business Administration - Health Service Management
- BS degree - Business Administration
LA GRANGE, KY 01/2017-CURRENT
The Rawlings Group was formed in 1977 to offer legal services to insurance providers. Rawlings launched what would ultimately become the first subrogation outsourcing program for the healthcare industry. The Rawlings Group is focused exclusively on recovery services for their health insurance company clients. They are the largest and most successful company in this segment of the market. Healthcare Claims Auditor (Current)
Reviews/audits healthcare claims, and investigates to determine Medicare/Commercial primacy by recognizing and investigating
known indicators, and communicating with healthcare providers, employers, members and/or Medicare representatives to gather information to support the primacy determination. Utilizes all available resources to maximize identification and recovery of overpayments, and complies with all company policies/procedures and state and federal laws during the investigation process.
• Answers all phone calls in a timely fashion and resolves issues satisfactorily and in compliance with company policies and procedures.
• Performs administrative tasks required for the invoicing and recovery process. Creates and maintains files in accordance with management policies and guidelines by obtaining and attaching all appropriate documentation to clearly identify an audit trail for the audit performed.
• Closes all files in accordance with required coding and approvals according to division guidelines.
- Healthcare Claims Auditor (Current) at THE RAWLINGS GROUP
- Underwriter at HEARTLAND PAYMENT SYSTEMS
- at HEARTLAND PAYMENT SYSTEMS
- Customer Advocate at HEARTLAND PAYMENT SYSTEMS
2 years, 2 months at this Job
- High school
• Audit and review of customer claims per trust, client and fiduciary and/or class action.
• Ability to maintain fast paced production quality utilizing strong attention to detail
• Responsible for the re-testing and monitoring of call center calls and on-line chats for quality control
• Conduct compliance testing, quality assurance and audits with 98% quality and 99.7% approval rate
- Claims Auditor at Delaware Claims Processing
- Fraud Analyst II at Bank of America
- Compliance Control Analyst at Independent Control Testing
- Customer Level Collections Account Specialist at
3 years, 2 months at this Job
- B.S. - Criminal Justice
Review claims for accuracy and assign errors as needed per SOP’s. I review anything medical from special accounts to high dollar claims.
- Claims Auditor at Cigna
- Claims Adjuster I at Cigna
- Medical and Dental Claims Processor at Cigna
- Front Desk Agent at winston hospitality/winstar
2 months at this Job
- Bachelor's - Healthcare Administration
• 40 hour work weeks
• Inbound call center taking calls to assist customers with their needs.
• Process claims
- Claims Auditor at Alorica
- Customer Service Representative at IBEX Global - Frontier Communications
- Office Coordinator at Tidewater Physicians Multispecialty Group
- Customer Loyalty Associate at The Roomstore Furniture
4 months at this Job
- High School Diploma - Business management
• Apply claim processing experience to investigate, audit and analyze all levels of claims processing procedures and workflows.
• Independently run reports on errors identified for potential error trends and report the results to Claims Management System and KOFAX.
• Provide final review according to GAP standards and submit for payment.
• Offer advice to customers in order to deliver appropriate solutions to the member
• Determine legal liability and equitably settle/defend in compliance with Safe Guard regulatory requirements.
- Claims Auditor at Safe Guard
- Claims Adjuster at
- Customer Service Representative at
- Fine Jewelry Salesperson at BERNARD PASSMAN
3 years, 10 months at this Job
- Bachelor's - Business Administration
- Associate - Business Administration
* Review adjudicated claims * Follow Medicare and Coding guidelines * Follow company coverage per their SPD * Submit clean claims for payment in a timely manner
- Claims Auditor at Pequot Health
- Claims Examiner at Pequot Health, TPA
- Coding/Billing Specialist at Rhode Island Hospital
- Coding Specialist at Memorial Hospital of RI
1 year, 2 months at this Job
• Led a three-person team to analyze and audit paid healthcare claims to determine if overpayment existed.
• Improved operational efficiency of auditing system by 15% through implementation of streamlined data-management procedures.
• Provided training and support of data architecture tools to new employees and coworkers.
- Claims Auditor at WESTERN GROWERS
- Assistant Financial Analyst at Covered California
- Finance Intern at Ernst & Young
1 year, 2 months at this Job
- Bachelor's - Economics and Statistics, Accounting (Minor)
• Performing complex audits of paper and electronic claims for payment integrity in alignment with regulatory standards and timelines, business policy, contractual requirements, appropriate coding, and system configuration.
• Analysis of audit results and communicating areas of concern to the appropriate staff and helping develop recommendations for improvement and corrective action plans, and monitoring the execution of such plans.
• Identifying the root of problems and errors and working with the appropriate staff to resolve such issues.
• Constantly maintain current knowledge of all changing regulatory requirements in respect to Medicare and Medi-Cal guidelines.
• Developing training materials, policies and procedures for staff to ensure a high level of accuracy.
• Working with other departments and providers to help improve efficiency and work quality and regularly attending interdepartmental meetings and finding a proactive solution to discussed areas of issues.
- Claims Auditor at Independence Medical Group
- Claims Auditor at PPMC
- Claims Supervisor/Lead Auditor at MAGNOLIA HEALTHCARE MANAGEMENT
- Claims Supervisor at NETWORK MEDICAL MANAGEMENT
1 year, 2 months at this Job
- B.S. - Pre-Medical