Managed Care Auditor OLL

The Managed Care Contract Auditor is responsible for auditing the accuracy of payments made by the Managed Care companies for services rendered at the hospital.  In addition, the position is responsible for reporting results in an effort to improve internal processes and communicate payment problems to Managed Care and the Business Office. 

1.       1.   Audit Analysis and Reporting
2.       2.   Collaboration and Partnership
3.       3.   Other Duties As Assigned

• Audits report from decision support system to compare expected payments with actual payments. Compares contract terms to payment to determine appropriate billing, timeliness, and accuracy of payment.
• Specifies, produces, and analyzes a standard set of utilization and medical expense reports to support the assessment and cost effectiveness of managed care contracts. Maintains report showing audit results and communicates results of audits to Business Office and Managed Care Departments.
• Identifies trends related to specific payers and/or internal process problems that negatively impact hospital cash flow.
• Performs audits of inaccurately adjudicated accounts and reconciles to the contract and corresponding explanation of benefits.
• Assists with issues identified related to contract modeling, billing, registration, denials, etc.
• Works collaboratively with the Managed Care Operations Coordinator to resolve identified issues with managed care companies.
• Coordinates and reports audit outcome regarding payment errors, percentage of savings or losses, and works closely with the assigned collection staff and Business Office for process improvement and account follow up.
• Promotes the quality and efficiency of his/her own performance through participation in staff educational programs, approved continuing education courses, and specialized skill training programs.
• Performs other duties as assigned or requested.
• At least 3 years' experience in health care billing/claims adjudication
• High School or equivalent