CLAIMS AUDITOR

ResponsibilitiesSUMMARY: Responsible for auditing and training claims staff on all Managed Care claims received from outside providers to ensure the Claims Examiners processed and adjudicated them accurately and consistently in accordance with outside Provider Contracts, State, Federal, CMS, DMHC and Health Plan contracts, internal departmental policies and procedures. Must maintain a productivity standard of auditing 15 claims per hour.QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Some knowledge of Microsoft Word, Excel and Access database software programs is required.QualificationsEDUCATION and/or EXPERIENCE: High school diploma or general education degree (GED); or Four (4) or more years with claims processing experience and/or training; or equivalent combination of education and experience. Must possess a strong knowledge of the Centers for Medicare and Medicaid Services (CMS), the Department of Managed Health Care (DMHC) and HMO standards and requirements.

Created: 2025-10-04