Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing Whole-Person Care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 3,500 providers including Primary Care, Specialty, Hospital System and ancillary provider partnerships. We have operated in the Arizona market for more than 10 years, and are based in Chandler, Arizona. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing costs.

The medical claims auditor will be responsible for checking the claim for completeness, for compliance with procedures and to ensure that the costs are in line with the service or diagnosis received by utilizing online reference, Plan Summary Descriptions, Provider Contracts, and/or current coding manuals. Medical Claims Auditor must be experienced and extremely detail-oriented, precise and thorough. Knowledge of facility and ancillary claims processing experience is required. Knowledge of medical terminology is a must, as is a broad understanding of health insurance administration processes and standard guidelines. Knowledge of CPT, HCPCS, and ICD-9 Coding is essential.

Primary Job Duties and Responsibilities

· Audit completed claims for all products / Ensure daily self-audit report are performed by the claims team.

· Perform all daily self-audit reports.

· Audits randomly selected claims to ensure quality processing.

· Follows adjudication policies and procedures to ensure proper payment of claims.

· Follows the eligibility research protocol including verifying member benefits and COB.

· Review authorization status codes and notes affecting the adjudication of the claim.

· Submit claims inquiry to UM per protocol.

· Perform audits of claims involving high dollar and network specialty pools.

· Apply provider contract rates appropriately based on effective dates and amendment updates.

· Meet productivity and error ratio standard as required.

· Reconcile Health Plan error reports as required.

· Adjudicate professional, facility and high dollar claims in accordance with Managed Care Operations, CMS and AZPC Guidelines.

· Researches reports from various data sources for management.

· Analyzes audit results for trends and root cause issues.

· Maintains/track production and quality scores for each employee.

· Creates and maintains auditing policies and procedures.

· Conduct periodic post audit of claims to alleviate any incorrect decisions

· Communication with management on audit findings, assist with error validation process

· Utilizes the plan documents in order to properly adjudicate claims and answer questions regarding claims. Fee schedules and Medicare regulations are provided for determining proper payment.

· Research and resolve, working with Claim team, customer service issues in a timely manner to ensure quality claims service.

· Assist claims management in training of team regarding contract application and disseminating info regarding adjudication policies and procedures.

· All Other Duties as assigned.

EDUCATION, TRAINING AND EXPERIENCE

· High school diploma or equivalent required.

· Minimum 5 years recent claims experience.

· Claims auditing experience desired.

· Knowledge of medicine and medical terminology, CPT, HCPCS, ICD.9, and DSM codes

· Must have experience with UB92 forms

· Strong knowledge of Medicare Billing & Payment Guidelines as well as CMS CCI Edits

· Familiar with all regulatory requirements including CMS and DHS

· Must be able to work under general guidance of Claims Lead with little direct supervision

· Must be meticulous and pay attention to detail.

· EZ-Cap Experience is a plus

· Strong data entry skills (10,000 keys strokes alpha/numerical)

· Must be able to work independently and exercise judgment

· Must be able to work on computer systems, accessing multiple files

*This role requires FT in-office presence for the first 90 days of employment. Hybrid schedule available after initial training period.*

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Chandler, AZ 85226: Reliably commute or planning to relocate before starting work (Required)

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Ability to commute/relocate:

• Chandler, AZ 85226: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Claims: 5 years (Preferred)

Work Location: Hybrid remote in Chandler, AZ 85226

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