Claims Quality Auditor in San Diego, CA at Scripps Health Plan Services -4S Ranch

Date Posted: 8/1/2019

Job Snapshot

Job Description

At Scripps Health, you will experience the pride, support and respect of an organization that has been repeatedly recognized as one of the nation’s Top 100 Places to Work.

You’ll be surrounded by people committed to making a difference in the lives of their patients and their teammates. So if you’re open to change, go ahead and unlock your potential.

As a nationally recognized health system, Scripps Health is committed to providing the highest quality care to our patients. Bring your valuable talents to our Financial Services team as a Claims Quality Auditor. Our Financial Services Teams boasts a spirit of continuous improvement and a commitment to making a difference in the lives of our patients. Looking for an individual who looks at things in a logical, organized and detailed fashion to make a positive impact on the organization.

The Claims Quality Auditor will audit claims for coding accuracy, ensure correct interpretations and definition of benefits, contract interpretation and in compliance with policies and procedures. It will be your responsibility to select claims through random processes and/or other criteria. Determine whether to return, deny, or pay claims following organizational policies and procedures. You will also handle escalated and unresolved claims including audit preparation. The position shall support all claims payment recovery functions, Provider Dispute Resolutions, collections, oversight of Coordination of Benefits (COB) functions as well as Third Party Liability (TPL) activities. It is your responsibility to ensure compliance and turnaround times are consistently being met or exceeded by working applicable assignment and ensuring the release of claims inventory. In addition, you will test new version releases relative to claims, benefits administration and/or provider contract and document results. Conducts research to determine if system updates are needed and submits requests to Claims Department or IS for implementation. You will also provide guidance or expertise to less experienced claims processors and offshore team.

This is a Full Time, 8 Hour Monday – Friday Day position, located at our 4S Ranch/Rancho Bernardo Business Services office.

Job Requirements

Required Education/Experience/Specialized Skills:
  • Three years of healthcare claims processing experience.
  • Experience with medical terminology, CPT/HCPCS/ICD10 Codes.
  • Excellent written and verbal communication skills.
  • The ability to apply critical thinking for analyzing complex claims issues.

Preferred Education/Experience/Specialized Skills/Certification:
  • Five or more years of experience in processing and adjudicating claims.
  • Claims auditing experience a plus.
  • Associate’s Degree or above
  • CPC Certification

Scripps Health is repeatedly named on the Fortune Magazine’s 100 Best Companies to work for, only San Diego-based company and Becker’s Healthcare Top Hospitals. Scripps Health offers a robust Total Rewards Program designed to compensate and motivate you throughout your career. Scripps Health Total Rewards Program includes a broad range of plans and programs including market competitive pay and performance incentives, health and wellness benefits, financial wellness benefits, work-life resources, learning and development opportunities, and rewards and recognition. Unlock your potential with Scripps Health today.

Scripps Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, age, status as a protected veteran, among other things, or status as a qualified individual with disability.