NO EXPERIENCE NECESSARY- WE WILL TRAIN
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REPORTS TO: Quality Assurance Team Leader LOCATION: Missoula or WAH FLSA STATUS: Non-Exempt
POSITION RESPONSIBILITIES:
Through a respectful, constructive and energetic style guided by the objectives of the company, the Health Claims Auditor’s primary responsibilities are to audit health, dental and vision claims, and provide value-added information through effective communication. This position is designed to: Obtain results which are representative of actual performance; measure claim payment accuracy by a method which is consistent with World Class insurance standards and provide a tool for management for improving claim administration accuracy and projecting an overall-position image of the audit process.
The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and to be respectful and courteous in the conduct of this position.
ESSENTIAL JOB FUNCTIONS:
Essential job functions include the following. Other functions may be assigned as business conditions change.
Establish a statistically valid audit sample that is aligned with generally accepted industry practices
Develop and maintain a structured audit approach to ensure accuracy and consistency of results
Audit health, dental and vision claims
Prepare on-going reports of findings which includes recommendations to management to improve process and overall results
Develop process that will ensure the integrity and ongoing quality of the audit process
Consistently maintain a high level of professionalism and cooperation at all times when dealing with in-house staff and outside contacts
Produce monthly audit reports
Contribute to the daily workflow with regular and punctual attendance
Communication and Confidentiality Expectations:
Because communication is one of the most critical skills of this position, the incumbent must possess excellent language skills. Providing value-added information to the organization is what auditing is all about. It is critical to give feedback to the Manager of Service Teams regarding the people being audited in a positive, objective and constructive manner and realize that the person you are auditing has a positive intention behind their actions. In order for the incumbent to be successful in this position, they must build rapport and trust with staff so that feedback can be received and processed in a positive perspective. It is also critical to maintain a high level of confidentiality relating to audit process and performance of individual Claims department employees.
Auditing Reports:
All auditing reports and findings should be communicated to the Training Team Leader, Training and QA Manager, Health Team Leaders, and Health Service Operations Managers.
Denials/Problem Claims:
All errors/questions on denials or problem claims should be directed to Examiner first and then if further review is needed then to the Training Team Leader/Training and QA Manager.
NON-ESSENTIAL JOB FUNCTIONS:
Performs related or other assigned duties as required or directed.
SUPERVISION EXERCISED:
N/A
PHYSICAL WORKING CONDITIONS:
Physical requirements are representative of those that must be met to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Sitting 100% Reaching Some
Standing None Manual Dexterity Medium
Walking None Telephone Yes
Kneeling None Computer Screen High (visual acuity corrected to 20/30)
Bending None Lifting None
JOB SPECIFICATIONS:
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.
Minimum Education: High school graduation or GED required. College degree preferred.
Certification(s) Required: None.
Minimum Experience: Previous health claims processing required. Experience with computers and customer service required. Previous supervisory or management experience preferred.
Other Qualifications:
Excellent oral and written communication skills required.
PC skills, including Windows, Word and Excel. Must be able to adapt to software changes as they occur.
Ability to learn all functions of the health claims processing software program and adapt to software changes as they occur.
Basic accounting and mathematical skills.
Ability to enter data with accuracy and precision.
High level of interpersonal skills to work effectively with others.
Ability to organize and recall large amounts of information including interactions with employees, agents, plan participants and clients.
Ability to read, analyze and interpret benefit summary plan descriptions, insurance documents and regulations.
Ability to project a professional image and positive attitude in any work environment.
Ability to comply with privacy and confidentiality standards.
Ability to analyze and solve problems with professionalism and patience, and to exercise good judgment when making decisions.
Ability to motivate and inspire staff to achieve goals and perform at a level expected by the company.
Ability to operate typical office equipment.
Working knowledge of general office procedures.
Maintain and high level of professionalism and objectivity
Ability to build effective and positive working relationships
The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel as classified.