Claims Quality Auditor jobs in Maryland
Claims Quality Auditor audits claims for coding accuracy, benefit payment, contract interpretation, and compliance with policies and procedures. Selects claims through random processes and/or other criteria. Being a Claims Quality Auditor makes recommendations to improve quality, workflow processes, policies and procedures. Typically requires an associate degree. Additionally, Claims Quality Auditor typically reports to a supervisor or a manager. The Claims Quality Auditor gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Claims Quality Auditor typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
Recently Added Claims Quality Auditor jobs
Claims Quality Auditor
- HealthCare Resolution Services, Inc.
-
Columbia, MD
FULL_TIME
-
Description Of Services
Audit a portion, as mutually agreed between the parties, of the combined financially stratified/attribute claim sample of medical and dental claims processed by medical care administrators. During the identified audit period (i.e., audits performed in 2024 will review claims processed through January 1, 2023 - through December 31, 2023, etc.). The audits will be conducted virtually with each administrator.
Tasks, Activities and Deliverables
The Claims Audit Elements Include Review And Validation
The claimant was eligible for benefits on the date(s) of service based on data in the administrator's eligibility files,- The provider's network participation was correctly determined based on the date of service,
- Claims requiring utilization review approval were reviewed and processed in accordance with utilization review decisions,
- Deductibles, coinsurance and other appropriate cost-sharing features of the benefit plan were considered and correctly applied,
- The claim data was entered into the claim system correctly, and whether a paper claim was keyed or scanned,
- Appropriate checks were made to ensure that there was no other coverage available to the claimant or, if there was other coverage, payments were coordinated correctly,
- The "reasonable and customary" or provider discount features of the plan were correctly applied, including unbundling for physician services,
- Appropriate edits were made to ensure that the claim was not paid twice,
- The procedure(s) billed and paid were, in fact, covered by the plan and do not appear to be fraudulent billings by the provider,
- The mathematics and computations were correct,
- Any pre-authorization limits were appropriately applied,
- The paper claim form was completed appropriately and signed by the appropriate parties,
- The administrator adhered to its own internal policies and procedures when processing the claim,
- Appropriate approvals were applied to high dollar claims (pre- and post-payment), and
- Sufficient documentation was included in the file to support the adjudication of the claim.
- Bachelor's degree in accounting, finance, or a related field such as health information management.
- At least three years of experience as a claims auditor or similar role in the health care industry.
- Strong analytical and problem-solving skills
- Excellent attention to detail
- Ability to communicate complex information effectively and clearly
- Good understanding of insurance policies and regulations
- Proficiency in using computer software such as Microsoft Office Suite
- Ability to work independently and in a team environment.
- High level of integrity and ethical behavior.
- Strong organizational and time-management skills.
- Flexible and adaptable to change.
- 3 Days Ago
Senior Quality Medical Claims Auditor I
- Kaiser Permanente
-
Hyattsville, MD
OTHER
- Job Summary:Remote from any KP location in CA, OR, CO, WA, GA, MD, VA, HI or D.C. Only. ** PLEASE NOTE: Salary ranges are geographically based and the posted range reflects the MD region. Salary range...
- 27 Days Ago
Night Auditor
- Quality Inn Waldorf
-
Waldorf, MD
FULL_TIME
- Job Summary The Night Auditor is responsible for the preparation and disposition of all Night Audit work. Responsible for the front desk operation during the overnight shift (Typically 11pm-7am). Prim...
- 12 Days Ago
Quality Auditor
- H&H
-
Annapolis, MD
FULL_TIME
- We are offering an exciting opportunity for a Quality Auditor to join the H&H Quality Department in our Annapolis, MD office.The Quality Auditor will carry out internal H&H project audits for ongoing ...
- 5 Days Ago
SCA Quality Auditor I
- Anthem
-
Baltimore, MD
FULL_TIME
- SHIFT: Day Job SCHEDULE: Full-time Be part of an extraordinary team! We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the commu...
- 7 Days Ago
Quality Auditor (Onsite)
- Experis
-
Rosedale, MD
CONTRACTOR
- Job Title – Materials CoordinatorOur client in (Rosedale, MD 21237) is looking for hardworking, motivated talent to join their team. Don’t wait… apply today!Shifts9a-6p Quality Role x 2 opening (7a-4p...
- 7 Days Ago
Claims Quality Auditor jobs at Popular Companies
Quality Auditor
- ResourceMFG
-
Jacksonville, FL
- summary ResourceMFG is now hiring Quality Auditors in Lafayette! Pay and Hours: 2nd Shift: 2:30pm-11pm-$20/hr Job Descri...
- 6/11/2024 12:00:00 AM
Quality Auditor
- Texas Children's Hospital
-
Bellaire, TX
- Job Summary We are searching for a Quality Auditor - Benefits, Contracts, Fee Schedules Configuration/Testing - someone ...
- 6/11/2024 12:00:00 AM
Quality Auditor
- Loma Linda University Health
-
Loma Linda, CA
- Job Description Job Summary: The Quality Auditor will be responsible for auditing departmental workflows and functions, ...
- 6/11/2024 12:00:00 AM
Quality Auditor
- Catalent Pharma Solutions
-
Madison, WI
- **Quality Auditor** **Position Summary:** Catalent is a global, high-growth, public company, and a leading partner for t...
- 6/9/2024 12:00:00 AM
Quality Auditor
- Flextronics
-
Salt Lake City, UT
- Job Posting Start Date 04-26-2024 Job Posting End Date 06-26-2024Flex is the diversified manufacturing partner of choice...
- 6/8/2024 12:00:00 AM
Quality Auditor
- Plastipak Holdings
-
Jackson Center, OH
- As a Plastipak Quality Auditor, you audit systems and processes as they relate to our Quality program. You play a key ro...
- 6/7/2024 12:00:00 AM
Quality Auditor
- Amsted Automotive Group
-
Sterling Heights, MI
- ABOUT THE ROLE Means TransForm Products is now the newest business unit of the Amsted Automotive Group, a premier techno...
- 6/7/2024 12:00:00 AM
Quality Auditor
- Mauser Packaging Solutions
-
York, PA
- JOB DESCRIPTION Responsibilities Performs quality assurance testing as required. Reviews production orders or schedules ...
- 5/23/2024 12:00:00 AM
About Maryland
Maryland (US: /ˈmɛrələnd/ (listen) MERR-əl-ənd) is a state in the Mid-Atlantic region of the United States, bordering Virginia, West Virginia, and the District of Columbia to its south and west; Pennsylvania to its north; and Delaware to its east. The state's largest city is Baltimore, and its capital is Annapolis. Among its occasional nicknames are Old Line State, the Free State, and the Chesapeake Bay State. It is named after the English queen Henrietta Maria, known in England as Queen Mary.
Sixteen of Maryland's twenty-three counties border the tidal waters of the Chesapeake Bay estuary and...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Claims Quality Auditor jobs
$47,652 to $58,410
Most Popular Cities in Maryland for Claims Quality Auditor Jobs
What does a Claims Quality Auditor do?
Claims Quality Auditor in Bloomington, IN
Evaluates claims activities of other departments and / or companies.
December 05, 2019