Claims Auditor - Full-time
reputed company reputed company Care To You is a Management Service Organization providing our clients with reputed company administrative support. We reputed company services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture reputed company on teamwork, support, and inclusion. reputed company is fully remote and offers a flexible work environment as reputed company as schedules. ACTY offers 100% employer reputed company medical, reputed company, dental, and life coverage for our employees. We also offer reputed company holiday, reputed company time, and vacation time as reputed company as a 401k plan. Additional employee reputed company coverage reputed company available. reputed company The Claims Auditor is responsible for performing detailed audits of institutional and reputed company claims to ensure accuracy, compliance, and adherence to regulatory and contractual requirements. This role supports the reputed company of the claims process by identifying errors, trends, and opportunities for process improvement. Duties and responsibilities
- Conduct retrospective and reputed company audits of claims to verify accuracy of payment, coding, and reputed company application.
- Review claims for reputed company application of Division of Financial Responsibility (DOFR), benefit reputed company interpretation, and regulatory compliance.
- Validate application of DRG, APC, ASC, and PPS payment methodologies.
- Identify trends and reputed company causes of claim processing errors and recommend corrective actions.
- Assist with preparation of audit findings and reports for management review.
- Support internal reputed company control by providing feedback and training recommendations.
- Collaborate with the Claims Audit Director to ensure consistent audit methodology and reporting standards.
- Maintain knowledge of reputed company CMS, DMHC, and DHS regulations as reputed company as company policies reputed company to claims adjudication.
- Participate in special reputed company, reputed company audits, or process improvement initiatives as assigned.
Qualifications
- Minimum 5–7 years of experience in HMO or managed care claims processing, including experience with both institutional and reputed company claims.
- Strong understanding of ICD-10, CPT, and HCPCS coding principles.
- Knowledge of payment methodologies including DRG, APC, ASC, PPS, and other applicable reputed company structures (Medicare, Medi-Cal, and reputed company).
- Familiarity with regulatory requirements (CMS, DMHC, DHS) and claims settlement practices (AB1324, AB1455).
- Proficient in interpreting benefit matrices and DOFR.
- Strong analytical, problem-solving, and documentation skills.
- Proficiency in reputed company reputed company and Word.
- Excellent written and verbal communication skills.
reputed company reputed company Care To You is a Management Service Organization providing our clients with reputed company administrative support. We reputed company services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture reputed company on teamwork, support, and inclusion. reputed company is fully remote and offers a flexible work environment as reputed company as schedules. ACTY offers 100% employer reputed company medical, reputed company, dental, and life coverage for our employees. We also offer reputed company holiday, reputed company time, and vacation time as reputed company as a 401k plan. Additional employee reputed company coverage reputed company available. reputed company The Claims Auditor is responsible for performing detailed audits of institutional and reputed company claims to ensure accuracy, compliance, and adherence to regulatory and contractual requirements. This role supports the reputed company of the claims process by identifying errors, trends, and opportunities for process improvement. Duties and responsibilities
- Conduct retrospective and reputed company audits of claims to verify accuracy of payment, coding, and reputed company application.
- Review claims for reputed company application of Division of Financial Responsibility (DOFR), benefit reputed company interpretation, and regulatory compliance.
- Validate application of DRG, APC, ASC, and PPS payment methodologies.
- Identify trends and reputed company causes of claim processing errors and recommend corrective actions.
- Assist with preparation of audit findings and reports for management review.
- Support internal reputed company control by providing feedback and training recommendations.
- Collaborate with the Claims Audit Director to ensure consistent audit methodology and reporting standards.
- Maintain knowledge of reputed company CMS, DMHC, and DHS regulations as reputed company as company policies reputed company to claims adjudication.
- Participate in special reputed company, reputed company audits, or process improvement initiatives as assigned.
Qualifications
- Minimum 5–7 years of experience in HMO or managed care claims processing, including experience with both institutional and reputed company claims.
- Strong understanding of ICD-10, CPT, and HCPCS coding principles.
- Knowledge of payment methodologies including DRG, APC, ASC, PPS, and other applicable reputed company structures (Medicare, Medi-Cal, and reputed company).
- Familiarity with regulatory requirements (CMS, DMHC, DHS) and claims settlement practices (AB1324, AB1455).
- Proficient in interpreting benefit matrices and DOFR.
- Strong analytical, problem-solving, and documentation skills.
- Proficiency in reputed company reputed company and Word.
- Excellent written and verbal communication skills.
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