Claims Auditor

The vision of Colorado Access is to have healthy communities transformed by the care that people want at a cost we can all afford. Our mission is to partner with communities and empower people through access to quality, affordable care.

Why should you consider a career with Colorado Access?

We are a Colorado-based company, working to improve the health of our state. We care for individuals, families, and children who receive health care under Child Health Plan Plus (CHP+) and Health First Colorado (Colorado's Medicaid Program). Our focus is driving improvements in quality, member experience, outcomes, and cost. We are a mission-driven organization whose foundation is built by our vision, supported by our values and pillared by diversity, equity and inclusion.

1. Find work/life balance: We offer PTO, floating holidays, seven company paid holidays, work from home options (exceptions apply), an Employee Assistance Program and a 401K.
2. Be a part of something bigger and make an impact : We serve the underserved and most vulnerable populations in our community through access to quality and affordable health care. No matter what you do for Colorado Access, you are impacting our community and making a difference.
3. Sharpen your skills, learn, and grow : We support your continued development through tuition reimbursement, leadership training, promotion opportunities, performance evaluations, employee recognition, and a language pay stipend.

What you will do:

We are looking for a Claims Auditor who can help shape our vision and support our mission. Here is what the position will look like.

• Audits random samples of manually and auto-adjudicated claims with an emphasis on claims processing accuracy (payment and process accuracy). This may include auditing claims directly or reviewing claims randomly audited by the BPO through an “Audit the Auditor” quality program.
• Conducts audits of high dollar claims according to department policy and line of business configuration processes.
• Conduct post pay audits of claims according to contract, benefit plan language, and provide individual claims examiners with meaningful feedback in regard to findings.
• Conduct pre pay audits of claims when appropriate.
• Participate in the external audit process by gathering and submitting required documentation and reviewing feedback from external auditors such as SCIO.
• Summarize and report auditing results to Manager, escalates any issues from monitoring.
• Maintain productivity standards to effectively handle multiple, concurrent priorities and consistently meet established deadlines.
• Update and create procedural documentation to support accurate manual claims processing activities as applicable
• Identifying top errors and improvements, identifying strengths, escalating areas of improvement and tracking best practices.
• Work Special projects from start to end from providers, and or COA staff.
• Perform monthly audit samples on the benefit coding, reimbursement, and pricing.
• Identify system issues, escalate, and submit tickets as appropriate to the configuration team.
• Create and test benefit coding by using scripts & scenarios developed in model office.
• Identify and Coordinate Medical Record Review with UM, Compliance, and Quality as needed.
• Quality Improvement Initiatives, Including:
  • Act as a claims subject matter expert and facilitate discussions with cross-functional teams to improve quality and maintain the integrity of claims quality as system solutions are implemented.
  • Track and report results of quality improvement initiatives.

What you will bring:

Education : High School Diploma or equivalent required.

Experience : Minimum of five years’ experience in a claims processing role in a managed care environment. Quality assurance experience with an emphasis on claims auditing preferred. Previous experience in Medicaid or Medicare a plus.

Knowledge, Skills, and Abilities : Solid knowledge of managed care, which includes CPT, HCPC, Revenue andICD10 coding for Medicaid and Medicare and commercial products. Proficient in Microsoft Office products including Excel and Access. Excellent written, verbal and interpersonal communication skills. Demonstrates support for the company’s mission, vision and values. Ability to develop and monitor effective quality assurance procedures. Ability to identify specific training needs based on review of eligibility records and communicates those needs to the Client Service Management team effectively. Strong organization, time management and decision-making skills required. May be required to manage multiple priorities and projects with tight deadlines.

Licenses/Certifications : A valid driver's license and proof of current auto insurance will be required for any position requiring driving.

Together we will be : an innovative and collaborative team who supports each other, the employees and vision of the company to reach our goals individually, together and as an organization.

Pay, Perks and Benefits at Colorado Access:

The compensation for this position is $63,000.00 - $75,600.00 annually. The pay rate/salary is commensurate with experience.

In addition to being part of a mission driven organization serving our community, as an eligible Colorado Access employee, you’ll receive a generous benefits package, that includes:

• Medical, dental, vision insurance that starts the first day of the month following start date.
• Supplemental insurance such as critical illness and accidental injury.
• Health care and dependent care flexible spending account options.
• Employer-paid basic life insurance and AD&D (employee, spouse and dependent).
• Short-term and long-term disability coverage.
• Voluntary life insurance (employee, spouse, dependent).
• Paid time off
• Retirement plan
• Tuition reimbursement (based on eligibility).
• Annual bonus program (based on eligibility, requirements and performance).

Where you will work:

This position will be a hybrid model work environment, a blend of ‘In-Office’ and ‘Remote.’

We are not able to support out of state employees at this time as we continue to serve our members and community in the metro Denver area and across the beautiful state of Colorado.

Colorado Access is committed to providing equal opportunities to all people regardless of race, color, national origin, age, sex, genetic information, religion, pregnancy, disability, sexual orientation, veteran status or any other status protected by applicable law. We strive to maintain a work environment that is free from unlawful harassment and discrimination.