Claims Auditing Specialist IV

Investigates claims reviews/appeals by performing audits to validate conformance with policies and payment methodologies and analyzing data to identify problems. Evaluates audit processes by developing/testing criteria to ensure processes are compliant, conducting assessments to ensure data and quality standards are maintained, and providing feedback. Documents claims outcomes by determining coverage eligibility, and preparing reports of findings, and offering thoughts on resolving the issue. Facilitates the resolution of payment discrepancies by using strategies, responding to findings, addressing issues, and coordinating /audits. Contributes to compliance processes by developing/reviewing training and procedure requirements, developing instructional material, assigning work, and participating in trainings. Facilitates efforts to optimize system improvements by identifying/investigating issues, researching and providing feedback on process efficiencies, generating reports/reporting systems, and suggesting policy changes to improve processes.

• Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.


• Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.


• Documents the resolution and reporting of claims outcomes by: determining coverage eligibility for moderately complex claims for which written guidance used to make determinations requires some interpretation; and preparing and presenting standard and non-standard reports with moderate complexity to notify management and regional management of audit findings, claims issues, and provider utilization trends.


• Evaluates audit processes by: developing and testing audit criteria to ensure moderately complex audit processes are compliant with contract terms, policies, procedures, practices and internal controls, and state and federal laws; and conducting quality assessments of payment and audit processes to ensure data integrity and quality standards are maintained across the audit process and providing feedback to managers and operations team.


• Investigates claims reviews and appeals by: performing comprehensive, moderately complex audits of medical claims payment and invoice data (e.g., claim adjustments, refunds, provider disputes) to validate conformance with specified coverage policies and payment methodologies using independent judgment; and analyzing data to identify problems of a moderate scope relating to service utilization, utilization review, referrals, transfers/diverts, claims and financial strategies of providers.


• Contributes to efforts to monitor and optimize system improvements by: identifying issues and working with supervisors and other team members to investigate department-wide issues impacting metrics related to pricing, billing, cost containment, and benefit compliance; identifying technology and operational process efficiencies and providing feedback on solutions to improve workforce management and claims processing accuracy; generating standard reports and/or notifications and/or developing operational management dashboards in partnership with reporting groups to monitor performance metrics; and making changes to standard and non-standard policy and implementing strategies to improve internal processes and controls and ensure that assigned processes meet regulatory guidelines as specified by all relevant regulatory agencies.


• Contributes to compliance working processes by: working with management to develop training requirements for internal claims team in response to changes in policies, procedures, regulations, or new trends in claims processing; reviewing and/or participating in the development of moderately complex instructional material for team members and department stakeholders with limited direction; and participating in approved trainings on topics related to claims systems, processes, data, and policies as instructed.


• Supports the resolution of payment discrepancies for services by: using advanced knowledge of business practices to select and use collection and recoupment strategies needed to remediate payments from members or provider services; responding to findings and/or disputes between KP and payers, which requires expertise and judgment, escalating as needed; communicating with other departments to ensure compliance and payment accuracy from outside providers are documented; and monitoring and posting specialized transactions, refunds, adjustments, or overpayments to notify members and providers of payment owed.