Role Overview
This role reviews medical paid claims against provider contracts and policies to ensure medical payments have been processed accurately. The incumbent will employ data mining and coordination of benefit techniques to analyze and audit hospital and physician claims to identify errant claim payments.
What You Will Do
Achieve measured production, quality, and growth results. Utilize analytics, data mining and coordination of benefit techniques to client paid claims data, develop creative and innovative algorithms and queries that facilitate identification of new savings opportunities.
Why It Might Be a Fit
Must be able to prioritize, coordinate, multitask, think outside the box, and be energetic. Must be able to work independently while maintaining close attention to detail.
Requirements
- Minimum high school diploma or GED along with four (4) years of direct experience in medical claims investigation or data mining / coordination of benefits auditing.
- Attainment of relevant medical billing and coding certification along with a bachelor’s degree in a relevant field are both highly preferred.
- Advanced knowledge of coding type edits and medical claim reimbursement structures and methodologies.
- Advanced proficiency with medical terminology, medical procedures, medical conditions, and illness and treatment practices.
- Expertise in COB NAIC Guidelines.
- Extensive experience in applying principles of coding guidelines; federal/state regulations and policies pertaining to coding and billing.
- Subject matter expert in reviewing and interpreting medium to complex medical contracts.
- Experience providing guidance to other employees on coding regulations and reimbursement structures.
- Extensive knowledge in researching state and federal healthcare guidelines, including Medicare and State Medicaid Programs.
- Familiarity with automated medical claims payment systems and/or working knowledge of payer systems such as Facets and QNXT.
- Advanced computer skills and proficiency with Microsoft Excel.
- Required licensures, professional certifications, and/or Board certifications as applicable.
Benefits
- Medical, dental and vision coverage with low deductible & copay
- Life insurance
- Short and long-term disability
- Paid Parental Leave
- 401(k) + match
- Employee Stock Purchase Plan
- Generous Paid Time Off – accrued based on years of service
- 10 paid company holidays
- Tuition reimbursement
- Flexible Spending Account
- Employee Assistance Program
- Sick time benefits – for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year
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