Data Integrity Auditor

Claims Data Integrity Auditor - (Peoria, Arizona)

Company Overview:

Arizona Integrated Physicians (AIP) is a physician-owned, physician governed organization comprised of 150+ independent primary care and 460+ independent specialist physicians. Originally founded in 1994, AIP has evolved to be a recognized leader in the Arizona market for delivering accessible, high quality, evidence-based healthcare services to Medicare Advantage (MA) beneficiaries in the West Valley. AIP has continued to grow as an aligned physician network and virtual medical group, enhancing the relevancy of independent physicians through clinical and business integration activities with an ongoing commitment to quality and health improvement.

Job Summary:

Primary responsibility for this position is to detect claim processing errors and overpayments made by Third Party Payers. The Data Integrity Auditor performs focused, quantitative and statistical healthcare claim audits in accordance with State and Federal regulations, network provider contracts, benefit coverage’s and other procedural policies influencing data integrity and reporting. Responsibilities include reviewing claim processing transactions, system configuration and other claim database source(s) detecting high value claim errors in critical, costly areas; Recording and analyzing audit results and preparing written audit reports noting deficiencies and highlighting significant variations, trends and patterns; Communicating errors and/or data anomalies to Payer(s), requesting corrective action and monitoring Payer(s) for timely follow up to corrective action request and corresponding claim adjustments. This position also supports AIP’s independent physician practices with business and clinical integration, by performing activities required for successful operations and fulfillment of AIP’s vision, mission and goals.

Qualifying Requirements:

  1. Bachelor’s degree or combination of equivalent related education and work experience, with minimum of 5 years claims auditing experience in a managed care claims department and a thorough understanding of auditing concepts, principles and critical elements included in the audit process.
  2. Must be able to write simple data extract queries using MS Access or Crystal or SQL.
  3. Requires strong analytical skills and the innate ability to interpret contracts.
  4. Working knowledge of Medicare coverage determinations and Medicare parts A, B, C and D.
  5. Working knowledge of Federal (ERISA, HIPAA, HITECT) and State legislation governing claims processing and benefit administration.
  6. Ability to follow appropriate methodology, sample selections, statistical analysis, basic interpretation of results, problem solving and formulation of appropriate recommendations.
  7. Must have experience using a variety of claims systems.
  8. Exceptional knowledge of healthcare coding conventions, coding principles and coding competencies, including ICD-9/10, CPT, DRG, Revenue, HCPCS and Medicare CCI, ME, MUE, etc.
  9. Proficiency with MS Office Suite, especially Excel, Word, and Power-point, with advanced knowledge of Excel (ability to create complex formulas, pivot tables, vlookups) and MS Access to build databases.
  10. Requires well-developed oral and written communication skills characterized by the ability to explain complex procedures clearly and concisely.
  11. Ability to adapt to a frequently changing regulatory and business environment.

Compensation & Benefits:

Compensation for this position is market competitive, depending on knowledge, skill and medical claim auditing experience. In addition, AIP offers a competitive compensation package that includes: Medical and Dental Coverage, Vision, Flexible Spending Acct, Basic Life Ins/AD&D, 401K plan, Paid Time Off / Holidays observed, Direct Deposit.


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