Claims Audit Specialist II

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer.
All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve.
We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.
Perform claim audits and report on results to identify training needs and system or process issues.
Reprocess claims due to processing errors, setup/system errors, eligibility updates, corrected billing and other retro changes.
Determine if rebills meet standards for required documentation, content, and timeliness and reprocess or communicate denial as necessary.
Review and make determinations on escalated/advanced rebills.
Responsible for all aspects of the Payment Check Run including auditing/reconciling claims processing and payment, pursuing EMG approval and releasing funds.
Responsible for identifying overpayments, preparing recovery requests, and performing follow-up tasks on outstanding overpayments.
Review, research, and make determinations on contested refunds.
Research and resolve accumulator issues.
Responsible for outsourced claims review vendor invoice tracking and resolution.
Provide subject matter expert (SME) level support regarding overpayment transactions and claims processing rules/procedures.
Perform the functions of a Claims Audit Specialist I.
Essential Responsibilities: Perform random and problem-focused audits of claims by researching benefits, reimbursement contracts, claim edits and claim policies and procedures, comparing to the processed claim.
Provide immediate feedback on claims with errors to claims analysts and team leaders.
Review claims, verifying accuracy of data entry including patient information, procedure and diagnosis codes, amount(s) billed, and provider data.
Review plan benefits and determine coverage based on contract and claims processing guidelines.
Accurately resolve or reprocess claims to correct processing, setup and/or system errors identified through multiple channels according to the instructions provided for the project.
Evaluate claims reprocessing requests to determine compliance with claims reprocessing standards prior to adjusting claims.
Accurately resolve or reprocess claims due to updated eligibility, benefits or provider status.
Complete the Weekly Payment Check Run.
Perform in-depth audits on high-dollar claims prior to releasing payment.
Reconcile payment with Finance to determine reporting/claims issues and resolve as necessary.
Pursue and monitor EMG approval, providing educated and thorough responses to any questions/concerns.
Reroute checks and correct errors if necessary.
Determine when all criteria for payment are met, communicate status, and release funds.
Review corrected claims/rebills from providers and facilities and determine if the request meets standards for required documentation and timeliness.
Review chart notes, claim itemization and other documentation.
Reprocess claim(s) if rebill meets standards for adjustment.
Communicate denial if the rebill does not meet standards and/or requires additional documentation.
Review, research and make determinations on advanced rebills, demonstrating a high level understanding of medical documentation, billing/coding, and claims processing guidelines.
Research, resolve and provide guidance on accumulator issues.
Determine accuracy of claims accumulation based on the benefit and policy provisions of the given plan/product.
Advise sales, customer service and others on the guidelines/procedures regarding accumulators.
Process accumulator credit reports from prior carriers and accumulator transfers for new/renewing groups.
Work assigned reports to monitor and/or correct claims for specific processing reasons.
Assist in processing other specialty claims/projects as workload or auditing requires.
Identify overpayments and prepare recovery requests.
Follow up with both members and providers on outstanding overpayments.
Research, reconcile and post refunds against affected claims.
Review, research and make decisions on contested refunds.
Determine if the contested refund meets standards for required documentation and timeliness.
Review documentation and make determinations on the validity of the contestation.
Correct claims processing or communicate non-acceptance as necessary.
Provide SME-level service to internal and external customers via customer service tasks, audit email queue, and phone etc.
to reprocess claims, answer questions and resolve refund issues.
Responsible for resolving advanced customer service tasks (Audit Specialist/Audit Team Lead queues).
Advise and assist other departments regarding billing/coding guidelines, claims processing guidelines and other issues.
Provide in-depth claims-related education as necessary to Configuration Analysts, Provider Service Representatives, Sales Representatives, etc.
Participate in system upgrades, providing testing/support as required.
Create documentation and facilitate training on changes resulting from system upgrades.
Take a lead role in training/mentoring team members.
Develop, update and maintain training materials/documentation and deliver one-on-one or group training to Claims Analysts and other Claims Audit Specialists using Lean training techniques as assigned.
Document issues that affect other PacificSource departments and advise appropriate internal personnel of claims processing concerns and/or problems.
Use established communication channels to notify internal departments and personnel.
Document issues that affect claims processing quality and advise team leaders of claims processing or system configuration concerns and/or problems.
Assist in claim grievance and appeal research and resolution.
Develop and maintain positive relationships with outside vendors that contract with PacificSource for claims related services.
May communicate via phone, email, or business letter.
Supporting Responsibilities: Actively participates in department or inter-departmental workgroups.
Shares information or issues with department leaders.
Regularly attend team meetings and daily team Visual Board huddle.
Meet department and company performance and attendance expectations.
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.
Work Experience: Minimum of three years claims adjudication or auditing experience.
Education, Certificates, Licenses: Requires high school diploma or equivalent.
Knowledge: Thorough understanding of PacificSource products, plan designs, provider/network relationships, health insurance terminology and industry requirements.
Advanced research/troubleshooting skills and ability to evaluate, diagnose and resolve claims processing issues.
Computer skills including keyboarding and 10-key proficiency, basic Microsoft Word and Excel.
Ability to prioritize work and perform under time constraints with minimal direct supervision.
Proactive, clear, and concise communication at all levels and with all types of customers.
Ability to develop Lean training materials and deliver claims training to others.
A fundamental understanding of self-insured business is helpful.
Competencies: Adaptability Building Customer Loyalty Building Strategic Work Relationships Building Trust Continuous Improvement Contributing to Team Success Planning and Organizing Work Standards Environment: Work inside in a general office setting with ergonomically configured equipment.
Travel is required approximately 5% of the time.
Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Our Values We live and breathe our values.
In fact, our culture is driven by these seven core values which guide us in how we do business: We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for customer service.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our many communities-internally and externally.
We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend.
Sit and/or stand for extended periods of time while performing core job functions.
Repetitive motions to include typing, sorting and filing.
Light lifting and carrying of files and business materials.
Ability to read and comprehend both written and spoken English.
Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change.
It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position.
Employment remains AT-WILL at all times.