Claims Audit Analyst - Denver Health Medical Plan (Must Live in Colorado. Weekly On-Site Requirement)
Core
Perform audits on claims processed by vendors, review provider escalations and grievances, and monitor member accumulators to ensure adherence to CMS, DOI, and contractual rules.
Role type
Claims Audit Analyst
Builds
Accurate claims payments and compliance with regulatory requirements
Domain
Healthcare administration / Managed Care
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
Claims auditing, QNXT system knowledge, UB-04/CMS1500/ICD-10 coding, Medicare/Medicaid program knowledge, Data analysis, Smartsheet usage, DRG/RBRVS understanding
Preferred skills
Total Claims Capture and Control (TC3) experience, Webstrat proficiency, Business Intelligence Portals experience
Technologies
QNXT, Smartsheet, Webstrat, Excel, Word, PowerPoint, Business Intelligence Portals, Audit Tool
Responsibilities
Perform special claims audits and calibration assessments, review provider escalations and member appeals, monitor member accumulators for out-of-pocket limits, address specific pricing needs (transplant, DRG downcoding), conduct weekly check run reviews for abnormalities, support ad hoc data analysis
Seniority
Mid-level individual contributor