Claims Auditor/Claims Processor/Claims Examiner/Revenue Cycle Auditor
Job Description
Job Description
Position Summary
The Claims Auditor supports the Claims Department by analyzing workflows, policies, and reports to ensure accurate and compliant claims processing. This role is responsible for auditing claims, identifying discrepancies, and ensuring timely and appropriate reimbursement in accordance with regulatory and organizational guidelines.
Key Responsibilities
- Ensure compliance with HIPAA and maintain confidentiality of patient information
- Analyze claims processes, policies, and reports to ensure accuracy and efficiency
- Audit claims to ensure proper payments in accordance with Medicare, Medi-Cal, and internal guidelines
- Investigate and resolve payment discrepancies including overpayments, underpayments, and refunds
- Generate and review claims audit, status, and pending reports
- Assist in training and educating Claims Department staff
- Serve as a resource for providers, members, insurance carriers, and internal teams
- Respond to inquiries and resolve claim-related issues in a timely manner
- Maintain and generate system reports for tracking and analysis
- Collaborate with Claims Director to ensure compliance with legal and contractual requirements
- Prepare weekly and monthly quality and performance reports
- Review member liability denials and provider dispute resolution claims
- Perform additional duties as assigned
Required Qualifications
- High school diploma or equivalent
- Minimum 4 years of medical claims processing experience
- Strong knowledge of:
-
- HMO / IPA operations
- Medical terminology
- ICD-10, CPT, and RVS coding
- Medicare and Medi-Cal guidelines
- Proficiency in 10-key by touch
- Strong organizational and time management skills
- Ability to work under deadlines in a fast-paced environment
- Excellent verbal and written communication skills
- Familiarity with claims systems and applications
Preferred Qualifications
- Prior experience in Claims Department training or leadership
- Bilingual (Spanish or Chinese) preferred
Soft Skills & Competencies
- Strong attention to detail and analytical skills
- Professionalism and confidentiality in handling sensitive information
- Effective interpersonal and customer service skills
- Ability to work collaboratively across teams
- Strong problem-solving abilities
Customer Service & Teamwork Expectations
- Treat all individuals with respect, dignity, and compassion
- Maintain confidentiality and demonstrate professionalism at all times
- Communicate openly and constructively with team members
- Contribute to a positive and safe work environment
- Take initiative to maintain workplace cleanliness and safety
Work Environment & Physical Requirements
- Ability to communicate effectively (verbal and written)
- Must be able to read, write, and speak English fluently
- Regular interaction with staff, providers, and stakeholders
Company DescriptionAlphaProTemps is specialized in providing "best-in-class" professional staff augmentation services. These recruiting directives include temporary labor, contract sourcing, professional & technical niches, vendor-on-site, and managed service programs.
Company Description
AlphaProTemps is specialized in providing "best-in-class" professional staff augmentation services. These recruiting directives include temporary labor, contract sourcing, professional & technical niches, vendor-on-site, and managed service programs.