Hospital Claims Auditor

Moda Health•Portland, OR

2d•Remote

About The Position

Provides clinical and technical analysis for interpretation of appropriate procedural and diagnostic coding and payment of hospital inpatient claims and related inputs. Determines whether facilities are in compliance with industry billing standards. This is a FT WFH role.

Requirements

3 – 5 years’ experience as a hospital billing coordinator and/or auditor.
Certified Professional Coder.
2 years health insurance industry experience, with prior experience in auditing of hospital claims preferred.
RN, LPN or associate’s degree in nursing, BSN desired.
Prior experience in review of medical records.
Proficiency with Microsoft Office applications and internet research.
Strong organizational, analytical and problem-solving skills required.
Excellent oral and written communications.
Ability to work well under pressure in a complex and rapidly changing environment.
Maintain confidentiality and project a professional business appearance.
A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work.
Must be comfortable being on camera for virtual training and meetings.

Nice To Haves

BSN desired.

Responsibilities

Identifies billing irregularities on hospital bills and recommends next level of review, including telephonic discussions with hospital, or referral to vendor.
Recommends solutions to resolve billing inconsistencies.
Communicates claim payment decisions to processing staff and recommends and coordinates processes to review large dollar hospital claims.
Enhances and problem solves new or inconsistent claim payment and coding policies.
Determines, with use of decision tree, need for claims to be adjudicated with no further review, review records for internal audit.
Develops and documents hospital claims review and audit policies.
Provides advice and recommendations to Clinical Policy unit on proper system coding and editing related to benefits ensuring accurate claims payment.
Collaborates with other Moda areas to provide clinical policy representation at meetings to ensure that decisions, which affect claim processing, are appropriate and will result in cost effective, efficient, and accurate claims payment.
Reviews provider and member complaints and appeals to determine trends and recommend changes for continuous improvement edits related to coding.
Assists Healthcare Services and Provider Correspondence with written responses to inquiries.
Tracks reporting statistics and data and compile meaningful and appropriate reports.
Monitors contracted vendors that provide services to control claims expense through negotiation, audits, clinical editing, etc.
Assists Healthcare Services in review of appealed claims requiring interpretation of clinical and pricing documentation (including, but not limited to operative reports, office notes, and system data).
Communicates with vendors, and providers through written correspondence.
Handles phone inquiries regarding correct coding and/or clinical editing pertaining to hospital audits.
Provides education to employees and provider offices as needed to facilitate an understanding of correct claim coding, use of CPT, ICD10, HCPCS, etc.
Performs other related duties and projects assigned.