Claims Audit and Appeal Analyst

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People. Passion. Purpose. 

At P3 Health Partners, our promise is to guide our communities to better health, unburden clinicians, align incentives and engage patients.

We are a physician-led organization relentless in our mission to overcome all obstacles by positively disrupting the business of health care, transforming it from sickness care into wellness guidance.  

We are looking for a Claims Audit and Appeal Analyst.  If you are passionate about your work; eager to have fun; and motivated to be part of a fast-growing organization in Las Vegas, Nevada, then you should consider joining our team.

 Overall Purpose: 

The main function of this position is to audit professional claims for accurate processing per all contract, health plan, State and Federal regulations within payment compliance time limits.  This position will also be responsible for analyzing and processing provider claim appeals. 

Education and Experience: 

  • High school diploma or GED.  Some college preferred.

  • Claims Audit and Appeal Analyst must have significant experience (6-8 years minimum) in the Medical Claims payment industry specializing in professional and institutional claims payment and processing provider appeals.

  • Preferred 3-5 years of EZ-CAP claim adjudication experience. 

Knowledge, Skills and Abilities:  

  • Must have a strong understanding of any local, state and federal rules regarding the adjudication of medical benefits.

  • Personal computer with main frame emulation, claims management software, word processing and management software, 10-key adding machine, Imaging retrieval software, fax machine, copy machine, basic office aids.

  • Working knowledge of HMO operations, claims delegation compliance, and contract interpretation.

  • Strong knowledge of CPT, HCPCS, ICD-10, DRG and APC coding and CMS Guidelines.

  • Strong organizational and time management skills with the ability to prioritize individual workloads.

  • Must have excellent analytical and interpersonal skills.

Essential Functions: 

  • Responsible for quality and continuous improvement within the job scope.
  • Responsible for all actions/responsibilities as described in company-controlled documentation for this position.

  • Contributes to and supports the corporation’s quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation’s quality improvement efforts.

  • Conducts historical, pre-payment, and post-payment audits of all claim types  for accurate payment per contract, health plan, state and federal requirements.   

  • Process and resolve provider claim appeals within contract, health plan, state and federal compliance time limits.   
  • Answer questions for customer service regarding appeal decisions. 
  • Perform clean claim processing and adjustment adjudication for professional and institutional claims under-paid, over-paid, or in some other fashion incorrectly adjudicated.
  • Responsible for all actions/responsibilities as described in company-controlled documentation for this position.

  • Contributes to and supports the corporation’s quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation’s quality improvement efforts.

  • Performs other work-related duties and responsibilities as directed, assigned or requested.

  • Prepares detailed analysis on payment abnormalities and/or questionable payment practices.

  • Process appeals and draft resolution correspondence to the respective entity.

  • Record all claims appealed and updates leadership as needed.

  • Maintains productivity expectations.

Location: Las Vegas, NV
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