Job Title: Claims Auditor/Recovery
Target Compensation Range: $90,000 - $120,000/year, depending on the level of relevant qualifications and experience.
About Us:
Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.
SUMMARY: This position reports to the Associate Vice President of Claims Operations. The Auditor will be responsible for oversight of Claims processing for claims processed by the system or by a Claims Examiner. The Auditor will provide support to Claims Leadership and Examining Teams and provide important insight into procedural and financial audits and offer up improvements in the process.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:
- Ensure claims are processed in accordance with P&P and Medicare Guidelines.
- Provider feedback to Leadership Team on performance of Team.
- Ensure all requests are complete all required correspondence is attached to claims.
- Determine appropriate level of reimbursement based on DOFR and/or Provider Contracts.
- Ensure the team is meeting required audit standards for procedural and financial audits.
- Assist in resolving escalated requests from providers and patients.
- Support team in initiatives in improving claims efficiency.
- Alert leadership of complex issues that may arise.
- Develop and maintain effective working relationships with staff.
- Document all processes for claims and provide training materials.
- Report out on Claim Reporting and Metrics based on Claim Audits.
- Manage and create P&Ps for Claim Processing alongside of Claims AVP.
- Audit Encounter Submissions and ensure compliance.
- Assist with testing of system.
- Record refunds and retraction on system.
- Assist in Delegation oversight.
- Regular and consistent attendance
- Other duties as assigned
EDUCATION and/or EXPERIENCE:
- High School Diploma or equivalent experience as a claim’s processor
- Ability to work in a fast-paced environment.
- Proficient with medical coding and terminology
- Ability to adapt to changing environment
- Working knowledge of Medicare Claim Processing
- Reliability with a strong work ethic
- Ability to work overtime, when needed
- Work independently
- Expertise in Auditing of Claims
- Over 10 Years of experience with Medicare Managed Care.
BENEFITS:
- 401(k)
- Dental Insurance
- Health Insurance
- Life Insurance
- Vision Insurance
- Paid Time Off
