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Posted: Tuesday, October 24, 2017 8:42 PM

Position Purpose:Independently perform comprehensive audits of claims to source documents and identify incorrect payments.Design and conduct audit planning and wrap up of engagements.Utilize appropriate sources of information, including eligibility, enrollment and provider/facility contracts to conduct quality audits of claims, pre and post payments.Execute review of Cost Sharing Reductions (CSR) reconciliation logic to ensure CSRs are applied correctly.Confirm the accuracy of the accumulator process for deductible and out-of-pocket maximum.Analyze errors and determine root causes for appropriate classification and facilitate corrective action plans.Perform control total checks on the claims submitted to reconciliation tools.Understand and support the resolution of errors.Utilize audit software to provide written documentation regarding audit observations. Monitor federal and state regulations and contract changes for impact on claim payments and update audit criteria as necessary. Summarize and communicate quarterly audit and related findings, recommendations, process improvement opportunities and best practices and assist in the consolidation and presentation of metrics, as needed.Compare reconciliation reports against actuarial estimates on the member level. Coordinate and oversee testing of benefits to ensure benefit plan designs are applied correctly.Validate benefit package, components, and the final plan design.Education/Experience:Bachelor's degree in Accounting, Finance, Business or related field or equivalent experience. 3+ years of public accounting, internal audit or related operational or business experience. IT, Marketplace, auditing or health care industry experience required. Knowledge of CPT/HCPCS Coding - provided by Dice2+ years medical or pharmacy claims processing, training or auditing experience, knowledge of claim software systems


• Location: St. Louis

• Post ID: 34647442 stlouis is an interactive computer service that enables access by multiple users and should not be treated as the publisher or speaker of any information provided by another information content provider. © 2017