Claims Auditor - LH

At Luminare Health , our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.Join HCSC and be part of a purpose-driven company that will invest in your professional development.Job SummaryJob Purpose: This role is responsible for the evaluation, development, running, and/or providing testing updates. Scope of testing support includes project-driven enhancements, routine updates/requests for change and other enhancement activities where testing is deemed critical to Operational success, in adherence with company and industry quality standards. Role includes analysis of features/components/etc. and identification of enhancement opportunities.Job Responsibilities: • Pre-check run auditing on various reports prior to finalizing the check run. Works within timelines for auditing and manage all auditing according to schedule• Provide assistance with all Health Plan claim audits. Provide feedback to Management and Staff regarding auditing results• Complete Claims Appeals and 095 processes according to health plan and company guidelines in accordance with established timeframes.• Assist in establishing and communicating new and existing policy and procedures. Enhance department productivity by recommending improvements to workflow processes and organizational structure. Develops corrective action plans and participates in compliance investigations as needed.Required Job Qualifications: • Bachelor’s degree or equivalent experience required • At least 4-5 years or more experience in claim processing.• Specific knowledge of claims and processes in a Commercial BC/BS HMO organization.• Proficient in MS Office applications: Outlook, Excel, Word, Access, and PowerPoint• Extensive Knowledge of CPT 4, HCPCS, UB-04 and ICD-10 coding.• Medical terminology knowledge • Excellent interpersonal, oral and written communication skills• Strong attention to detail and organization• Able to work independently; strong analytic skills• Strong computer skills• Requires flexibility, to be able to switch priorities in positive and effective manner when directed by network leadership.• Ability to meet deadlines.• Must be able to work in fast paced sometime stressful environmentPreferred Job Qualifications:• Specific knowledge of claims and processes in a Commercial BC/BS HMO organization.• Proficient in MS Office applications: Outlook, Excel, Word, Access, and PowerPoint• Extensive Knowledge of CPT 4, HCPCS, UB-04 and ICD-10 coding.• Medical terminology knowledge • Excellent interpersonal, oral and written communication skills• Strong attention to detail and organization• Able to work independently; strong analytic skills• Strong computer skills• Requires flexibility, to be able to switch priorities in positive and effective manner when directed by network leadership.• Ability to meet deadlines.• Must be able to work in fast paced sometime stressful environment.Job Responsibilities: Pre-check run auditing on various reports prior to finalizing the check run. Works within timelines for auditing and manage all auditing according to scheduleProvide assistance with all Health Plan claim audits. Provide feedback to Management and Staff regarding auditing resultsComplete Claims Appeals and 095 processes according to health plan and company guidelines in accordance with established timeframes.Assist in establishing and communicating new and existing policy and procedures. Enhance department productivity by recommending improvements to workflow processes and organizational structure. Develops corrective action plans and participates in compliance investigations as needed.Required Job Qualifications: Bachelor’s degree or equivalent experience requiredAt least 4-5 years or more experience in claim processing.Specific knowledge of claims and processes in a Commercial BC/BS HMO organization.Proficient in MS Office applications: Outlook, Excel, Word, Access, and PowerPointExtensive Knowledge of CPT 4, HCPCS, UB-04 and ICD-10 coding.Medical terminology knowledgeExcellent interpersonal, oral and written communication skillsStrong attention to detail and organizationAble to work independently; strong analytic skillsStrong computer skillsRequires flexibility, to be able to switch priorities in positive and effective manner when directed by network leadership.Ability to meet deadlines.Must be able to work in fast paced sometime stressful environmentPreferred Job Qualifications:Specific knowledge of claims and processes in a Commercial BC/BS HMO organization.Proficient in MS Office applications: Outlook, Excel, Word, Access, and PowerPointExtensive Knowledge of CPT 4, HCPCS, UB-04 and ICD-10 coding.Medical terminology knowledgeExcellent interpersonal, oral and written communication skillsStrong attention to detail and organizationAble to work independently; strong analytic skillsStrong computer skillsRequires flexibility, to be able to switch priorities in positive and effective manner when directed by network leadership.Ability to meet deadlines.Must be able to work in fast paced sometime stressful environmentAre you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!EEO Statement:We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.Pay Transparency Statement:At Luminare, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for associates. The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.Min to Max Range:$42,200.00 - $79,300.00Exact compensation may vary based on skills, experience, and location.