Claim auditor vs medical claims processor

Differences between claim auditor and medical claims processor duties and responsibilities

Claim auditor example responsibilities.

• Work with department analyst to create measurement tools and methods for communicating results and managing QA analysis in compiling/reporting results.
• Bill and prepare claims appeals for Medicare, Medicaid, and private payers.
• Review medical records and charges of hospital, ambulatory surgery and physician bills to verify CPT, ICD-9 and HCPCS codes.
• Research and determine accuracy of ICD-9 and CPT codes on CMS 1500 and UB 92 claims forms on a daily basis.
• Evaluate DRG grouping and pricing information.
• Audit all claims types for a Medicare HMO plan.
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Medical claims processor example responsibilities.

• Enter UB 92 and 1500 HCFA medical claims into computer system manage and process insurance claims.
• Manage cases by aggressively directing the litigation process.
• Submit medical claims to commercial insurance companies, Medicare, and Medicaid for payment with use of ICD-9 and CPT coding.
• Review and verify patient account information against insurance program specifications, analyze surgical procedures and diagnoses using CPT-4 and ICD-9 codes.
• Acknowledge and enforces confidentiality in alignment with (HIPPA) guidelines.
• Audit encounters and ICD-10 codes to ensure correct coding and maximum reimbursement.
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