The Claim Auditor is responsible for ensuring that their assigned sampling of adjudicated claims for Texas Medicaid and CHIP programs are audited on a monthly basis. The Claim Auditor is responsible for routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory standards, timelines, business policy, provider and HHSC contracts, appropriate coding and system configuration. Audits may include physician, outpatient, inpatient, facility, and long term services and support claims. Results of the audits are to be communicated to the Claims Department. Production and operational reports must be provided to the Director of Compliance at the end of each month.
Bachelor's Degree or equivalent insurance or managed health care experience required.
Two years of claims/audit experience.
A minimum of three years in a claims processing environment.
Extensive knowledge of claims processing medical benefits, medical terminology and coding.
Must have strong organizational skills, problem solving and decision making skills.
Advanced knowledge of claim adjudication and benefit plan application for Medicaid and CHIP programs.
Microsoft Office skills including Word, Excel and Access.
Excellent customer service skills with ability to explain complicated benefit issues to staff and providers.
Certified Professional Coder (CPC) or other equivalent medical coding certification required.