Claims AuditorThe Claims Auditor assists in the Claims Department by analyzing procedures, policies and reports; ensures appropriate payment of claims and maintenance of the claims system as necessary.Specific skills needed include knowledge of HMO/or IPA operations; medical terminology; ICD-10, RVS, and CPT coding knowledge; knowledge of Medicare and Medi-Cal guidelines; 10-key skills by touch; excellent communication skills; knowledge of system applications; ability to function effectively under time deadlines; strong organizational skills.Required: Formal training will be indicated by a high school diploma or equivalent; four years medical claims processing.Preferred: Department Management to list.Duties and responsibilities include safeguarding and preserving the confidentiality of patient's protected health information in accordance with State and Federal (HIPAA) regulatory requirements, hospital and departmental policies; ensuring a safe patient environment and adherence to safety practices per policy; utilizing the approved process to resolve biophysical, psychological, educational and environmental needs of patient/significant other when administering care; assisting the Claims Director in the training and education of the Claims department staff; coordinating the generation and review of claims audit, status and pending claims reports ensuring authorized claims are paid in accordance with company guidelines; investigating, processing and tracking payment adjustments including refunds, overpayments and underpayments; acting as a confidential and professional resource for group providers and other staff; acting as a resource for providers, members, insurance carriers, attorneys and co-workers, researching and responding to questions in a timely manner; creating, maintaining and generating system reports; interfacing with the Claims Director to ensure claims processing functions meet legal and contractual requirements with regards to health plan audits; preparing and presenting weekly and monthly reports reflecting staff and departmental quality statistics; reviewing and auditing member liability denials and Provider Dispute Resolution claims to ensure compliance with regulatory requirements and passing audit scores from health plans; performing other duties as assigned.Teamwork/customer service responsibilities include displaying loyalty and pride in and upholding the confidentiality of patients, visitors, physicians, and co-workers; demonstrating commitment to open communication; demonstrating pride in the physical appearance of all properties.Personal qualities include commitment to open communication.Communication skills include talking or hearing essential to communicate with patients and staff; good communication skills; read, speaks and writes English fluently. Bilingual skills in Spanish/Chinese preferred.