Insurance auditor job description

Primarily responsible for the review and follow up on paid insurance claims (including $0.00 pay) and payor recoupments to successfully determine if reimbursement is accurate according to current contracted rates and follow up with payers on outstanding monies due for services rendered to a patient. This position will provide “root cause” analysis and reporting of revenue opportunities to ensure appropriate reimbursement.
Responsibilities
• Perform thorough research of paid claims (including $0.00 pay) for appropriate follow up with payer.
• Provide detailed analysis of findings and payer trends.
• Review claim remittances to determine reimbursement rates and methodologies used by the payer when processing the claim.
• Identify opportunities with underpayment or contract language that is determinant to reimbursement and report findings to leadership.
• Perform extensive review of high dollar accounts that are subject to alternative reimbursement terms to validate payments are in accordance with contracted rates.
• Responsible for reviewing and understanding explanation of benefits/remittance advice from third-party payers.
• Process and review incoming correspondence from payers related to underpayment or high dollar/outlier payment discrepancies.
• Audit, research accounts, payment posting, and contractuals to confirm the accuracy of the balance, financial class, and follow up schedule on the account.
• Phone contact with patient, physician office, attorney, etc. for additional information to provide payer in order to process claim in accordance with contracted rates.
• Communicate payment discrepancies to payer specific provider representatives via email, phone, or scheduled in-person meetings.
• Work with reimbursement and contract modeling team members to verify contracted rates are properly calculated with contract modeling system.
• Maintain regular contact with Managed Care & Contracting management team to ensure all new contract agreements/updated rates are received timely and effective dates for new rates are communicated to the appropriate Revenue Cycle teams.
• Prepare and submit letters, emails, faxes, online inquiries, appeals, and adjustments.
• Document all follow up efforts in a clear and concise manner into the AR system.
• Work assigned accounts as directed while reaching daily productivity goals.
• Complete tasks by deadline provided by leadership.
• Participate in system testing and training.
• Attend seminars as requested.
• Other duties as assigned.
Qualifications
Minimum Education and Experience
• High School Diploma or GED
• 2-3 years of billing, insurance follow-up or insurance payor experience
• Experience performing account resolution with third-party payors is preferred
• Experience in working with ICD-10, revenue codes, CPT-4 and HCPCS
• Moderate computer proficiency including working knowledge of MS Excel, Word and Outlook
Knowledge, Skills, and Abilities
• Ability to read and interpret documents, i.e. contracts, claims, instructions, policies and procedures in written (in English) form.
• Ability to calculate rates using mathematical skills.
• Ability to define problems, collect data, and establish facts to execute sound financial decisions in regard to patient account(s).
• Must have detailed knowledge of the uniform bill guidelines.
• Ability to be persistent in the follow up of underpaid or partially paid claims in a timely manner.
• Ability to review, comprehend, and discuss HCFA billing with Insurance or Government agencies.
• Knowledge of general insurance requirements.
• Experience working directly with EOBs, contractual adjustments, and payer contracts.
• General computer knowledge and working with electronic filing systems.
• Ability to communicate verbally and in writing with professionalism.
• Organizational and documentation skills to ensure timely follow-up and accurate record keeping.
• Ability to meet productivity expectations.
• Strong team player.
• Strong self-motivation to achieve goals.