Claims Auditor

Claims Auditor

Alignment Healthcare was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time.

By becoming a part of the Alignment Healthcare team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community.

Position Summary: 
The Claims Auditor is responsible for reviewing claims processed by examiners based on provider and health plan contractual agreements and claims processing guidelines. Follows all internal processes and procedures to ensure claims audit activities are handled in accordance with departmental and company policies and procedures. Excellent knowledge of claims processing rules and Medicare regulatory requirements. Maintains production standards as established by departmental management to meet quality requirements, ensure payment integrity, identify root cause and training opportunities.

General Duties/Responsibilities:

(May include but are not limited to)

• Reviews claims for statistical and payment accuracy. Ensure appropriate payments or denials, and use of adjustment or reason codes are correct
• Identifies root cause of errors and work with internal departments for resolution
• Review claims for fraud, waste or abuse and notifies management of such findings.
• Updates systems, tracking tools or other documentation methods as needed.
• Identifies data trends and reports findings to department management with suggestion for resolution and opportunities for process improvement.
• Prepares and issue audit reports which include audit findings, scores and corrective actions
• Monitors completion of corrections
• Assists with training of claims examiners based on identified errors
• Submit monthly audit reports to Management.
• Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.
• Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.).
• Actively participates in ongoing training to support company and department initiatives.
• Supports department initiatives in improving processes and workflow efficiencies
• Adheres …