Overview

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Claims and Call Auditor (Call Center QC) - Clearwater, FL

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Summary:

The Claims & Call Auditor audits processed medical insurance claims and customer service calls to ensure validity, accuracy, and compliance with appropriate policies, procedures, and regulations

• Health, Dental, Vision, and Life Insurance as well as Paid Time Off and Paid Holidays!

Location: Clearwater, FL [Highpoint, ICOT] - On-Site, In-Office Position

Hours: Monday - Friday, 8:00AM-5:00PM

Responsibilities

Essential Duties and Responsibilities:

• In accordance with company guidelines, performs random audits, target audits, and audits for claims which are in excess of payment authority limits.

• Audits recorded customer service calls.

• Ensures compliance with appropriate company policies, procedures, guidelines, and reporting requirements; Federal and state regulations; and timeliness of claims processing.

• Prepares written audit reports based on findings and communicates audit findings with appropriate leadership.

• Identifies patterns, trends, and variances related to claims and calls and provides feedback to their Manager.

• Maintains up-to-date working knowledge on regulatory requirements associated with billing and claims processing.

• Reviews Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) to determine proper category for benefit code determination.

• Participates in all aspects of the organization’s Compliance Program.

Other Responsibilities:

• Adheres to the policies and procedures of PFC Shared Services.

• Maintains strict confidentiality of client, company and personnel information.

• Demonstrates a strong commitment to the mission and values of the organization.

• Adheres to company attendance standards.

• Performs other duties as assigned.

Supervisory Responsibilities: None

Competencies:

• Strong organizational and interpersonal skills

• Excellent written and verbal communication skills

• Detail oriented

• Ability to multi-task and work independently

Qualifications

Qualifications:

• Prior auditing experience is preferred

• Knowledge of medical terminology

• Knowledge of medical coding systems

• Knowledge of Medicaid/Medicare Guidelines

• Knowledge of billing rules and regulations.

• Strong organizational and interpersonal skills

• Excellent written and verbal communication skills

• Detail oriented

• Ability to multi-task and work independently

• Bilingual fluency is a plus [English/Spanish]

Education and/or Experience:

• A high school diploma or equivalent is required

• Experience in medical customer service, quality assurance, or insurance training is preferred.

Certificates, Licenses, Registrations:

None

Computer Skills:

Proficiency using software programs such as MS Word, PowerPoint, Excel and Outlook

Environmental Factors/Physical Demands:

Work is performed in an office environment. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor. May be subject to bending, reaching, kneeling, stooping and lifting up to thirty (30) pounds.

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Claims and Call Auditor (Call Center QC) - Clearwater, FL

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Job Locations US-FL-Clearwater

ID 2024-2600

# of Openings 1

Category Compliance