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Behavioral Health Claims Auditor

Company: Evolutions Treatment Center
Location: Miami
Posted on: November 25, 2022

Job Description:

Evolutions Treatment Center is looking to add a Behavioral Health Claims Auditor to their billing team! Please see below qualifications and responsibilities.


* Minimum of five years' experience in healthcare claims processing, or an equivalent combination of education, training and experience
* Strong understanding of claims processing workflow and payment rules
* Computer proficiency in a Windows environment, knowledge of Microsoft Office products with an emphasis in Excel
* Detailed knowledge of electronic billing processes and universal billing forms (UB04)

Strong knowledge of medical terminology, CPT Codes, HCPCs codes and ICD-10

Knowledge of Sunwave preferred, but not required

Strong written skills to accurately complete required documentation within the time frames specified

Ability to manage multiple tasks and prioritize work to adhere to deadlines and identified time frames

Ability to read, write and communicate at a professional level

Effective time management and organizational skills

Effective interpersonal and communication skills


The Claims Auditor ensures incoming claims are processed in accordance with policies, procedures and guidelines, as outlined by Evolutions Treatment Center and contractual agreements; within mandated time frames; and according to rates as reflected in respective provider contracts

The Claims Auditor will be responsible for pre-payment, post-payment validations and the management of operational reporting, testing and data submissions

Enter claim data accurately and timely, in alignment with departmental production and quality goals

Ensure claims payments are made within time frames as reflected in contractual agreements

Perform pre-payment audits and post payment audits to validate claims for appropriate coding and documentation (including but not limited to CPT, HCPCS, ICD-10 coding) and validate accurate claim adjudication rules and fee schedules were applied

Apply policies and procedures to confirm that claims meet criteria for payment and are in compliance with Evolutions Treatment Center contractual guidelines

Manage difficult, non-routine or escalated claims by using comprehensive research and thorough knowledge of Medicare payment rules

Identify and manage third party liability (TPL) or coordination of benefits (COB) cases reported by CMS, providers or members

Perform outreach and recovery efforts to Third Party Administrators
Outreach to providers for additional information, including medical records to validate Medical criteria is met prior to approving a claim for payment

Educate providers on billing requirements to reduce claim submission rejections and denials

Educate providers on prior authorization requirements

Create and distribute claim inventory and aging reports as needed

Assist in the effectuation of overturned appeals made by Evolutions Treatment Center

Assist in the research and resolution of payment disputes and appeals

Identify and refer potential fraud and abuse cases to the Compliance Department

Communicate identified trends to the Claims Department Supervisor for use in development of contracted provider training programs

Identify opportunities for claims adjudication process improvements

Assist in the training of new staff on claims processing policies, procedures and systems

Filing and light administrative duties associated with claims processing

Other duties and responsibilities as may be assigned

Job Type: Full-time

Pay: $20.00 - $22.00 per hour

* 401(k)
* Dental insurance
* Health insurance
* Life insurance
* Paid time off
* Vision insurance
* 8 hour shift
* Monday to Friday

* ICD-10: 1 year (Preferred)

Work Location: One location%58047475%

Keywords: Evolutions Treatment Center, Miami , Behavioral Health Claims Auditor, Other , Miami, Florida

Click here to apply!

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