Medical Claims Investigator

JOB SUMMARY:
This role reviews medical paid claims against provider contractsand policiesto ensure medical payments have been processedaccurately. Theincumbentwillemploy data mining and coordination of benefit techniques to analyze and audithospital and physician claimsto identify errant claim payments.

JOB ROLES AND RESPONSIBILITIES:
1. Achieve measured production, quality, and growth results.
2. Utilize analytics and data mining and coordination of benefits techniques to client paid claims data.
3. Evaluate medical claims for coding and pricing errors using accurate HCPCS, ICD-10, and CPT codes.
4. Lookup and review medical claims in payer system to determine methods of payment and validate savings identified.
5. Promote a positive team environment that is based around critical thinking and sharing intelligence to help meet both individual and team goals.
6. Utilize official coding guidelines and resources as required, including CMS directives and bulletins.
7. Collaborate, coordinate, and communicate across disciplines and departments.
8. Ensure compliance with HIPAA regulations and requirements.
9. Demonstrate Company's Core Competencies and values held within.
10. Please note due to the exposure of PHI sensitive data - this role is considered to be a High Risk Role.
11. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

JOB SCOPE:
This role keeps the needs of external and internal customers as a priority when making decisions and taking action. Will work under direct supervision to uncover actionable claims which facilitate savings for customers. Interacts with customers and internal staff in the organization.

JOB REQUIREMENTS (Education, Experience, and Training):
* Minimum high school diploma or GED along with two (2) 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 bachelors' degree in a relevant field are both highly preferred.
* Knowledge of coding type edits and medical claim reimbursement structures and methodologies
* Proficiency with medical terminology, medical procedures, medical conditions, and illness and treatment practices
* Experience in applying principles of coding guidelines; federal/state regulations and policies pertaining to coding and billing
* Knowledge in researching state and federal healthcare guidelines, i.e. Medicare and State Medicaid Programs
* Familiarity with automated medical claims payment systems and/or working knowledge of payer systems (i.e. Facets, QNXT, etc.)
* Advanced computer skills and proficiency with Microsoft Excel
* 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
* Required licensures, professional certifications, and/or Board certifications as applicable
* Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone

COMPENSATION:
The salary range for this position is $55k - $60K. Specific offers take into account a candidate's education, experience and skills, as well as the candidate's work location and internal equity. This position is also eligible for health insurance, 401k and bonus opportunity.

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