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Title

Claims Auditor  

Description

Peak Health Plan Management Services offers PACE third party back-office solutions, including claims processing, billing and health plan management solutions, along with over a decade of serving PACE/LIFE programs throughout the United States. Peak Health Plan Management Services operates as a service of Capstone Performance Systems, a subsidiary of Tabula Rasa HealthCare.

Summary: Under the supervision of the Chief Executive Officer, the Claims Auditor is responsible for auditing claims and conducting root cause analysis to ensure quality and ongoing compliance. The Claims Auditor will assist with the identification of trends and opportunities for improvement, and will provide appropriate feedback to the Claims Manager.

Option for remote or office-based work.

Essential Functions:

Auditing

  • Conducts a 5% post-claim, monthly random audit
  • Assists with new-examiner audits
  • Audits claims based on defined criteria
  • Determines if error is statistical, procedural or financial, or related to setup
  • Maintains audit summary report
  • Submits audit results to Claims Manager
  • Distributes audit summary reports to management monthly

Additional Functions:

  • Communicates clearly and concisely, with sensitivity to the needs of others
  • Maintains courteous, helpful and professional behavior on the job; displays a willingness and ability to be responsive in a warm and caring manner to all customer groups
  • Follows all Policies and Procedures and HIPAA regulations
  • Maintains a safe working environment
  • Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees
  • Establishes and maintains effective working relationships with co-workers

Supervisory Responsibility: None

FLSA Status: Non-exempt

Travel: Minimal travel, less than 10% is expected for this position.

 
Position Requirements
  • Education/Experience – Educational requirements include a high school diploma or equivalent. Three or more years of claims processing experience required.
  • Requires a working knowledge of quality audits and reporting.
  • Skilled in use of Windows-based claims processing applications, along with proficiency in Microsoft Word and Excel
  • Skilled in establishing and maintaining effective working relationships with co-workers and clients
  • Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency
  • Detail-oriented with ability to focus on projects for extended periods
  • Ability to work independently, seeking supervision as needed
  • Ability to communicate professionally, clearly and effectively, verbally and in writing
  • Ability to have superior attendance to effectively fulfill all functions of the position
  • Ability to independently follow through on assigned tasks, without prompting
  • Ability to prioritize effectively
  • Ability to consistently multitask

Physical Demands & Requirements:

  • Communicates by way of the telephone with participants, customers, vendors and staff
  • Operate a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
  • Remains stationary for extended periods of time
  • Frequently exerts up to 20 pounds of force to lift, carry, push, pull or move objects
  • Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy
  • Occasional reaching to retrieve shelved items

Work Environment:

  • This job operates in a home office or professional office environment with a conversational noise level.
  • No substantial exposure to adverse environmental conditions is expected
  • Moderate pressure to meet scheduled appointments and deadlines
  • Potential for occasional verbal aggression by clients and vendors
 
Full-Time/Part-Time Full-Time  
Shift Days  
Position Claims Auditor  
Post Internal Days 0  
Number of Openings 3  
Location Peak Health Plan Management- St Louis, MO  
About the Organization  
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.  
Cell None Specified 

HoursPerWk None Specified 

supervisorUID None Specified 


This position is currently not accepting applications.

To search for an open position, please go to http://TabulaRasaHealthcareInc.appone.com



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