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 certification
Internal Number: 37911
About Cook Children's Health Care System
Cook Children's Health Care System is a not-for-profit, nationally recognized pediatric health care organization comprised of eight entities – a Medical Center, Physician Network, Home Health company, Northeast Hospital, Pediatric Surgery Center, Health Plan, Health Services Inc., and Health Foundation.Cook Children's Medical Center Based in Fort Worth, Texas, the integrated system has more than 60 primary and specialty care offices throughout North Texas. Its service region includes Denton, Hood, Johnson, Parker, Tarrant and Wise counties, with an additional referral area encompassing nearly half the state.Cook Children's traces its roots back to 1918, but throughout its continual change and robust growth, it still embraces an inspiring promise – to improve the health of every child in its region through the prevention and treatment of illness, disease and injury. To live up to this promise, Cook Children's combines the art of caring with the use of leading technology and extraordinary collaboration to provide exceptional care for every child, every day.History – Cook Children's has a rich history of nearly a century of caring for children.Our Promise – Knowing that every child's ...life is sacred, it is the promise of Cook Children's to improve the health of every child in our region through the prevention and treatment of illness, disease and injury.Companies – Based in Fort Worth, Texas, Cook Children's is a not-for-profit organization that is comprised of eight nationally recognized companies.Community Health Outreach – Cook Children's Community Health Outreach works together with over 150 partner organizations to improve the safety and health of at-risk children through education, disease and injury prevention and support.Clinical Research – Cook Children's is home to a skilled team of research-minded physicians, nurses and health care professionals and administrators who drive our commitment to excellent clinical care and the search for medical advances.Public Relations – Cook Children's Public Relations works with national and local media outlets, produces Cook Children's publications, coordinates special events and helps develop key relationships within the community.Contractor & Vendor Information – Cook Children's contractors and vendors must ensure their employees are knowledgeable about working with our organization.Sponsorship guidelines – Cook Children's sponsors a select number of events that are strongly aligned with its promise to improve the health of every child in the region through the prevention and treatment of illness, disease and injury.