Medical Claims Investigator

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

Utilize analytics and data mining and coordination of benefits techniques to client paid claims data, evaluate medical claims for coding and pricing errors, and promote a positive team environment.

Why It Might Be a Fit

This role is a great fit for individuals with experience in medical claims investigation or data mining / coordination of benefits auditing, knowledge of coding type edits and medical claim reimbursement structures, and proficiency with medical terminology and automated medical claims payment systems.

Requirements

• Minimum high school diploma or GED
• Two (2) years of direct experience in medical claims investigation or data mining / coordination of benefits auditing
• Relevant medical billing and coding certification
• Bachelor’s degree in a relevant field
• 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
• Advanced computer skills and proficiency with Microsoft Excel

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
• Tuition reimbursement
• Flexible Spending Account
• Employee Assistance Program
• Sick time benefits

Originally posted on Himalayas