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Become A Claim Auditor

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Working As A Claim Auditor

  • Getting Information
  • Evaluating Information to Determine Compliance with Standards
  • Communicating with Supervisors, Peers, or Subordinates
  • Updating and Using Relevant Knowledge
  • Analyzing Data or Information
  • Deal with People

  • Mostly Sitting

  • $67,190

    Average Salary

What Does A Claim Auditor Do At General Electric

* Reviews, adjudicates, and approves reinsurance claims.
* Completes process, desk and/or field claim audits.
* Provides ongoing input and advice to clients on claim investigation, evaluation and payment.
* Creates, enhances and updates claim metrics and operation performance reviews.
* Produces, analyzes and acts on claim management reports and measures.
* Tracks and reports on claim changes, issues and trends.
* Helps identify process improvement and works with IT to explore system solutions.
* Coordinates efforts with broader claims team as well as other organization functions.
* Travel 20% for audits

What Does A Claim Auditor Do At Conduent

* Include but are not limited to)
* Manage and perform audits of medical claims payment data to validate conformance with specified coverage policies and payment methodologies as assigned.
* Review and understand the client’s Summary Plan Descriptions and Administrative Services Agreement.
* Work with IT to define the Plan parameters for use in reviewing electronic claim data within the audit software system.
* Review IT Audit Reporting, select and prepare valid audit sample following the standard departmental process and guidance received from the client.
* Travel to the administrator to conduct the site claim audit (potential for Travel up to 60% of the year, Monday through Friday).
* Work with Administrator to resolve exceptions, review supporting documentation and make final claim error determination.
* Ensure audit timeline is adhered to and deliver high quality service to clients
* Prepare or assist lead auditor in preparing audit reports which clearly articulate the audit methodology and audit findings.
* Audit reports must be supported by work papers.
* Provide support to field auditors when requested – prepping reports, QA on IT reporting and audit reports, sample selection, etc.
* Provide recommendations to Administrator for corrective action as well as identify areas for further consideration for delivery to the client and claims administrator.
* Work collaboratively within the audit team as well as with internal and external customers.
* Participate in team meetings, conference calls, WebEx’s, etc remotely / locally with administrators and audit team as necessary.
* Assist with Claims Data Analysis and Quality Assurance as requested

What Does A Claim Auditor Do At Chenega Corporation

* Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position)
* Conduct compliance review of medical, pharmacy and dental claims to evaluate the performance of Managed Care and other TRICARE contractors and ensure the integrity of Government payments, assist the Government in recoupment of unallowable health care costs.
* Perform focused evaluation studies involving comparability and trending of TRICARE contractor reimbursement practices with other government or national health care programs; provide recommendations for process improvements to TRICARE management; determine the soundness of various reimbursement practice requirements.
* Conduct research and analysis utilizing TRICARE Reimbursement, Policy, Operations, and System Manuals; the Center for Medicare and Medicaid Services (CMS) Manuals and pricing websites, and various automated TRICARE systems/applications and pricing modules/methodologies.
* Generate contractor audit performance reports.
* Prepare correspondence for distribution of audit documentation to TRICARE contractors, TRICARE Regional Offices and Contracting Officers as appropriate.
* Assist in development of various claim scenarios for benchmark testing of new or incumbent contractors prior to start work date of newly awarded contracts.
* Travel to contractor’s locations as a member of benchmark team to perform evaluation and review of contractor’s claims processing systems.
* Assists with the development of improper payment reports and provides meeting and analytical support
* Conducts focused studies; drafts correspondence requesting clarification of TRICARE policy language
* Conducts and interprets qualitative and quantitative analysis of data
* Prepares documentation for healthcare contractor reviews
* Manage the Documentum application - providing design, technical support, and problem analysis and resolution.
* Non
* Essential Duties:
* Other duties as assigned
* Supervisory Responsibilities:
* NONE

What Does A Claim Auditor Do At Pacific Dental Services, LLC

* Read and analyze EOB’s and make proper adjustments according to PDS claims processing criteria.
* Sends appeals to insurance carriers with justification as to why dental treatment should be paid.
* Audit accounts to ensure proper fees have been posted.
* Works with CBO team to maximize office collections and minimize adjustments.
* Communicate issues and suggestions to improve processes.
* Ensure compliance with Company policies as well as State, Federal and other regulatory bodies.
* Participate in meetings as required.
* Maintain an appropriate professional appearance and demeanor in accordance with Company policy.
* Other duties as assigned by management

What Does A Claim Auditor Do At Cedars-Sinai

* Conducts detail audits for compliance with State, Federal and Health Plan regulatory requirements
* Conducts pre-and post payment audits on adjudicated claims in compliance with Cedar
* Sinai policies, procedures and payment methodologies
* Documents audit findings and researches errors to determine root cause and makes recommendations for appropriate resolution
* Provides analysis and prepares recommendations to Management for errors and inconsistences
* Provides process improvement suggestions to Management
* Monitors appeals from providers, members and health plans to make sure they are processed accurately and in timely manner.
* Reviews error trends in processing and keep IS informed for system update.
* Monitors the daily auditing of processed claims and letters for accuracy.
* Distribute and monitor multiple projects to make sure deadlines are met.
* Process all check issues
*

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How To Become A Claim Auditor

Most accountants and auditors need at least a bachelor’s degree in accounting or a related field. Certification within a specific field of accounting improves job prospects. For example, many accountants become Certified Public Accountants (CPAs).  

Education

Most accountant and auditor positions require at least a bachelor’s degree in accounting or a related field. Some employers prefer to hire applicants who have a master’s degree, either in accounting or in business administration with a concentration in accounting.

A few universities and colleges offer specialized programs, such as a bachelor’s degree in internal auditing. In some cases, those with associate’s degrees, as well as bookkeepers and accounting clerks who meet the education and experience requirements set by their employers, get junior accounting positions and advance to accountant positions by showing their accounting skills on the job.

Many colleges help students gain practical experience through summer or part-time internships with public accounting or business firms.

Licenses, Certifications, and Registrations

Every accountant filing a report with the Securities and Exchange Commission (SEC) is required by law to be a Certified Public Accountant (CPA). Many other accountants choose to become a CPA to enhance their job prospects or to gain clients. Many employers will often pay the costs associated with the CPA exam.

CPAs are licensed by their state’s Board of Accountancy. Becoming a CPA requires passing a national exam and meeting other state requirements. Almost all states require CPA candidates to complete 150 semester hours of college coursework to be certified, which is 30 hours more than the usual 4-year bachelor’s degree. Many schools offer a 5-year combined bachelor’s and master’s degree to meet the 150-hour requirement, but a master’s degree is not required.

A few states allow a number of years of public accounting experience to substitute for a college degree.

All states use the four-part Uniform CPA Examination from the American Institute of Certified Public Accountants (AICPA). Candidates do not have to pass all four parts at once, but most states require that they pass all four parts within 18 months of passing their first part.

Almost all states require CPAs to take continuing education to keep their license.

Certification provides an advantage in the job market because it shows professional competence in a specialized field of accounting and auditing. Accountants and auditors seek certifications from a variety of professional societies. Some of the most common certifications are listed below:

The Institute of Management Accountants offers the Certified Management Accountant (CMA) to applicants who complete a bachelor’s degree. Applicants must have worked at least 2 years in management accounting, pass a two-part exam, agree to meet continuing education requirements, and comply with standards of professional conduct. The exam covers areas such as financial statement analysis, working-capital policy, capital structure, valuation issues, and risk management. 

The Institute of Internal Auditors (IIA) offers the Certified Internal Auditor (CIA) to graduates from accredited colleges and universities who have worked for 2 years as internal auditors and have passed a four-part exam. The IIA also offers the Certified in Control Self-Assessment (CCSA), Certified Government Auditing Professional (CGAP), Certified Financial Services Auditor (CFSA), and Certification in Risk Management Assurance (CRMA) to those who pass the exams and meet educational and experience requirements.

ISACA offers the Certified Information Systems Auditor (CISA) to candidates who pass an exam and have 5 years of experience auditing information systems. Information systems experience, financial or operational auditing experience, or related college credit hours can be substituted for up to 3 years of experience in information systems auditing, control, or security.

For accountants with a CPA, the AICPA offers the option to receive any or all of the Accredited in Business Valuation (ABV), Certified Information Technology Professional (CITP), or Personal Financial Specialist (PFS) certifications. The ABV requires a written exam, completion of at least six business valuation projects, and 75 hours of continuing education. The CITP requires 1,000 hours of business technology experience and 75 hours of continuing education. Candidates for the PFS also must complete a certain amount of work experience and continuing education, and pass a written exam.

Advancement

Some top executives and financial managers have a background in accounting, internal auditing, or finance.

Beginning public accountants often advance to positions with more responsibility in 1 or 2 years and to senior positions within another few years. Those who excel may become supervisors, managers, or partners; open their own public accounting firm; or transfer to executive positions in management accounting or internal auditing in private firms.

Management accountants often start as cost accountants, junior internal auditors, or trainees for other accounting positions. As they rise through the organization, they may advance to accounting manager, chief cost accountant, budget director, or manager of internal auditing. Some become controllers, treasurers, financial vice presidents, chief financial officers, or corporation presidents.

Public accountants, management accountants, and internal auditors can move from one aspect of accounting and auditing to another. Public accountants often move into management accounting or internal auditing. Management accountants may become internal auditors, and internal auditors may become management accountants. However, it is less common for management accountants or internal auditors to move into public accounting.

Important Qualities

Analytical skills. Accountants and auditors must be able to identify issues in documentation and suggest solutions. For example, public accountants use analytical skills in their work to minimize tax liability, and internal auditors use these skills to detect fraudulent use of funds.  

Communication skills. Accountants and auditors must be able to listen carefully to facts and concerns from clients, managers, and others. They must also be able to discuss the results of their work in both meetings and written reports.

Detail oriented. Accountants and auditors must pay attention to detail when compiling and examining documentation.

Math skills. Accountants and auditors must be able to analyze, compare, and interpret facts and figures, although complex math skills are not necessary.

Organizational skills. Strong organizational skills are important for accountants and auditors who often work with a range of financial documents for a variety of clients.

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Claim Auditor jobs

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Claim Auditor Demographics

Gender

  • Female

    75.0%
  • Male

    23.5%
  • Unknown

    1.5%

Ethnicity

  • White

    79.8%
  • Hispanic or Latino

    12.2%
  • Asian

    6.0%
  • Unknown

    1.4%
  • Black or African American

    0.6%
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Languages Spoken

  • Spanish

    64.3%
  • Hmong

    7.1%
  • Vietnamese

    3.6%
  • German

    3.6%
  • Greek

    3.6%
  • Carrier

    3.6%
  • Hindi

    3.6%
  • Urdu

    3.6%
  • Arabic

    3.6%
  • Italian

    3.6%
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Claim Auditor Education

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Top Skills for A Claim Auditor

AuditClaimsProcedureCodesMedicalProvidersMedicalInsuranceClaimsProcessClaimsCustomerServiceEligibilityMedicaidInsuranceCompaniesHealthInsuranceClaimsCpt-4HealthcareProvidersDataEntrySpecialProjectsFraudAuditFindingsCMSHighDollarClaimsClaimsPaymentDentalClaims

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Top Claim Auditor Skills

  1. Audit Claims
  2. Procedure Codes
  3. Medical Providers
You can check out examples of real life uses of top skills on resumes here:
  • Audit claims for billing, making sure all diagnosis, procedure codes, insurance information, and charges are entered correctly.
  • Use of Lotus Notes to submit additional pricing edits to the Professional Reimbursement Department for unlisted procedure codes.
  • Answer questions from claimants and medical providers on status of claims by phone calls.
  • Fort Scott* Checked medical insurance claims for mistakes by the examiner.
  • Collect and process claims and follow up of billed amounts and reporting activities.

Top Claim Auditor Employers

Claim Auditor Videos

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