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Healthfirst Clinical Service Auditor in Remote, New York

The Clinical Service Auditor examines claims and service authorizations to determine and correct any inaccuracies, prevent claim errors, and increase provider satisfaction.

  • Examines provider claims and service authorizations for completeness and accuracy.- Reviews different large sets of claims data to recommend changes in the claims submission and authorization processes- Communicates to Care Management teams any inaccuracies found along with recommended solutions.- Communicates with providers regarding any claim or authorization issues.- Reviews CPT procedure codes for verification of medical necessity.- Follows up with providers to ensure outstanding issues are resolved and to increase and promote overall provider satisfaction level.- Compiles recurring issues and deficiencies to be used in the re-education of the team to prevent errors.- Completes documentation in Patient Health Information database (CCMS).- Documents any provider complaints and/or incidents upon notification.- Notifies manager of any provider issues and concerns.- RightFax referrals and authorization approvals & denials upon provider’s request.- Other duties as necessary.

Minimum Qualifications:

  • HS diploma or GED

Preferred Qualifications:

  • Bachelor’s degree

  • Relevant previous work experience such as medical records review; claims processing; managed care plan products (e.g. Medicaid, Medicare, Commercial) and knowledge of Department of Health (DOH) and Local Department of Social Services and Center for Medicare & Medicaid Services (CMS) regulations pertaining to managed care; etc.

  • Experience working with any of the following systems: CareEnhance Clinical Management Software (CCMS), TrueCare, PEGA, Citrix, RightFax, VoIP, Virtual work platforms (VPN), Electronic medical record (EMR) database containing patient health information (PHI), and/or MACESS archival system.

  • Language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese.

  • Ability to build and maintain positive relationships with cross-functional teams and interact with all levels of management.

  • Intermediate Microsoft Word, Excel, and Outlook skills

  • Time management, critical/creative thinking, project management, communication, and problem-solving skills

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement (http://www.dol.gov/agencies/ofccp/posters)

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

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