Auditor

Position Code: 220b

Department:  Quality Assurance
Location: Nashville, Tennessee
Immediate Supervisor:  Pam Hackler
Status: Exempt
Posted: April 18 2017

Essential Functions of Job:

• Review health, vision and dental claims by applying HealthSCOPE Benefits’ audit program to a statistically valid sample of claims • Review claims for erroneous payments • Detect and document inappropriate procedures • Detect instances of fraud and abuse • Research and report on nationally accepted medical protocols and insure that they are consistently applied to claims data to identify deviations from the guidelines • Perform rejected claims analysis and review • Identify and assist with improvements of teaching aids such as training handbooks, demonstration models, multimedia visual aids, computer tutorials and reference works within the Training Department • Monitor and evaluate the quality of procedural improvements • Maintain knowledge of all claim processing techniques and procedures for customer base Includes, but is not limited, to client-specific documentation made publicly available as well as Claims Processing policies & procedures as stored in the Intranet folder • Provide monthly statistical reporting of results • Provide (at a minimum) monthly feedback to the Claims & Training Departments based on a trend analysis for the purpose of Training program developments • Perform other related duties as assigned • Ability to report to the office

Qualifications:

• College degree preferred, experience considered in lieu of degree • Previous Medical coding and processing • Effective organizational and prioritization skills • Excellent oral and written communication skills • Basic knowledge of Microsoft Office software applications (Word, Excel, Outlook, Access) • Ability to work in a fast paced multi-tasking environment • Strong interpersonal skills with ability to function as a positive team member • Ability to travel • Ability to read, comprehend and apply contract information, certification information and benefit manuals • Broad knowledge of Employer sponsored Group Health and Dental Plan Benefits, for interpretation of client’s plan document for analysis of claim payment accuracy is desired • Strong mathematical background for calculating Claim Audit Scores, plan benefits payable, etc. • Working knowledge of benefit design and software programming is a plus • 2-3 years experience in processing medical, dental and/or vision claims preferred

 

The Company considers applicants without regard to race, color, national origin, sex, religion, mental or physical disability, marital status, age 40 years and over, sexual orientation or gender identity, veteran's status, or other characteristic protected by applicable law.

Applications for this vacancy will be received for 3 working days after the Posted date from Employees of HealthSCOPE Benefits with more than one year of service.

Applications for this vacancy will be received for 10 working days after the Posted date from External Applicants.