• Senior Claims Auditor

    Job Locations US-CA-Fairfield
    Job ID
  • Overview

    To train all levels of Examiner and Customer Service staff on related claim processing functions for all lines of business using Amisys Advance system and Claims Operating Instruction Memorandums. Performs retrospective, concurrent, and special claims audits on all claim types for all PHC lines of business. Completes audit documentation and reports. Provides feedback and recommendations to the Claims Audit Supervisor and Associate Director of Claims Technical Support on department audit trends and staff training.


    • Trains all levels of Examiner and Customer Service staff.
    • Performs all claims audits.
    • Documents audits and reports all audit outcomes.
    • Provides feedback and recommendations on staff training needs and system adjustments.
    • Drafts Claims department training documentation.
    • Other duties as assigned.


    Education and Experience

    High school diploma or equivalent; minimum two (2) years of claims examining experience; or equivalent combination of education and experience; completion of PHC Claims training preferred; college course work in business or related field preferred.



    Special Skills, Licenses and Certifications

    Familiarity with Medi-Cal and/or managed care claims processing. Knowledge of CPT, HCPC procedure coding, and ICD-9/ICD-10 diagnostic coding. Typing speed 30 wpm and proficient use of 10-key calculator. Familiarity with AMISYS or similar claims systems. Understanding of claims examining requirements. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.



    Performance Based Competencies

    Excellent oral and written communication skills. Ability to effectively exercise good judgment within scope of authority and handle sensitive issues with tact and diplomacy. Ability to work on multiple tasks within established time frames and sometimes with conflicting priorities. Good organizational skills with ability to maintain accurate records and documentation of actions and decisions.



    Work Environment And Physical Demands

    Ability to use a computer keyboard. More than 80% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up to 25 lbs.




    Additional Preferred Skills: Knowledge of CIF processes. 



    All HealthPlan employees are expected to:


    • Provide the highest possible level of service to clients;
    • Promote teamwork and cooperative effort among employees;
    • Maintain safe practices; and
    • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.




    The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform.  The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.


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