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Medical Claims Auditor I

Date:  Jun 16, 2022

Any city, TX, US, 99999

Req ID:  10687


We are seeking a talented individual for a  Medical Claims Auditor I who performs research analytics to support our recovery audit line of business. Assists in the development and implementation of new data mining and audit/review methodologies for identifying healthcare overpayments and underpayments to providers, and the detection of healthcare fraud, waste, and abuse.

Job Description

Essential Responsibilities:

Participates in the review of health insurance claims and member eligibility information to uncover claims overpayment trends associated with non-compliance or misapplication of contract terms and rates, payment policies, medical policies, billing guidelines, and applicable regulatory requirements. Applies knowledge of provider billing and patient accounting practices to research of client policy and data to reveal new overpayment recovery opportunities. Works with data miners, clinical staff, and stakeholders to identify new overpayment issues for each client.
Tracks, and follows-up on results and recoveries
Contributes new ideas for improving existing audit processes and audit queries. Works cohesively with the audit team.
Develops, maintains, and ensures adherence to multiple project schedules


Knowledge, Skills and Abilities:
Sound understanding or medical terminology and anatomy.
Good understanding of Medicaid required, Medicare and commercial experience a plus.
In depth knowledge of coding principals including but not limited to NCCI Edits, CPT, HCPCS and ICD-9 codes and modifiers; and/or MSDRG, Revenue codes, and APCs.
In depth knowledge of UB04 and medical (1500) claim formats and requirements.


Minimum Related Work Experience:

1-3 years of healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, and/or revenue cycle improvement required.
Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-9-CM codes, HCPCS codes, CPT codes, DRGs, physician billing, etc. preferred.
Experience in healthcare auditing, reviewing and validating the accuracy of claims data and accuracy of claims payment preferred.
Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data, Recovery audit experience a plus preferred

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