Coding Investigator Auditor

HCSC•Chicago, IL

5d•Remote

About The Position

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job Summary This position is responsible for performing clinical, billing, coding and lowest cost setting reviews for services pre and post payment utilizing medical, contractual, legislative, policy, and other information to validate claims submitted and billed. Conducting research; preparing documentation of findings and consulting with medical directors as needed. Coordination with all departments involved in each case required such as special investigations, customer service, pass, network management, marketing, case management, medical review, legal, pricing and database.

Requirements

Bachelor Degree; one year of business experience, law enforcement experience, or regulatory agency experience may substitute for each year of college.
Certified Coding Certification, or acquire within 24 months of hire
3 years experience in claims processing operations and reporting systems, including 2 years experience in auditing or developing computer system reports.
Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation.
Awareness of claims processes and claims processing systems.
PC proficiency to include Microsoft Word and Excel and health insurance databases.
Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings.
Organizational skills and prioritization skills

Nice To Haves

Registered Nurse (RN) with unrestricted license in state.
Certified Coder preferred
3 plus years of claim adjudication/payment integrity
3 years clinical experience

Responsibilities

performing clinical, billing, coding and lowest cost setting reviews for services pre and post payment utilizing medical, contractual, legislative, policy, and other information to validate claims submitted and billed.
Conducting research
preparing documentation of findings
consulting with medical directors as needed.
Coordination with all departments involved in each case required such as special investigations, customer service, pass, network management, marketing, case management, medical review, legal, pricing and database.