Anthem, Inc. Claims Auditor Sr in Cerritos, California
SHIFT: Day Job
CLAIMS AUDITOR SR.
Location: Cerritos, CA Remote: w/potential to work in office post COVID Days
Claims Auditor Sr- Is responsible for pre and post payment and adjudication audits of high dollar claims across multiple lines of business, claim types and products including complex specialized claims within Service Experience. Serves as the subject matter expert for the unit. Primary duties may include but are not limited to: • Claims Auditor Sr- Performs audits of and may adjudicate complex high dollar claims while maintaining acceptable levels of claims inventory and age. • Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, system coding and pricing, pre-authorization, and medical necessity. • Contact’s others to obtain any necessary information. Completes and maintains detailed documentation of audit which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis. • Provides feedback on claims processing errors; identifies quality improvement opportunities and initiates complex system requests related to coding or system issues. • Refers overpayment opportunities to Recovery Team. • Serves as a subject matter expert for Policy and Clinical Guidelines. • Associates at this level serve as a mentor and resource to other audit staff. • Must possess strong research and problem-solving skills
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.
• Requires a high school diploma or GED; 4+ years related experience in a quality audit capacity (preferably in healthcare or insurance sector) with consistent above target performance; working knowledge of insurance industry and medical terminology. • detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines; and ability to acquire and perform progressively more complex skills and tasks in a production environment or any combination of education and experience which would provide an equivalent background. BA/BS degree preferred.