Medical Claims Investigator

Claritev•New York, NY

4d•Onsite

About The Position

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.

Requirements

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.
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

Nice To Haves

Attainment of relevant medical billing and coding certification along with a bachelors' degree in a relevant field are both highly preferred.

Responsibilities

Achieve measured production, quality, and growth results.
Utilize analytics and data mining and coordination of benefits techniques to client paid claims data.
Evaluate medical claims for coding and pricing errors using accurate HCPCS, ICD-10, and CPT codes.
Lookup and review medical claims in payer system to determine methods of payment and validate savings identified.
Promote a positive team environment that is based around critical thinking and sharing intelligence to help meet both individual and team goals.
Utilize official coding guidelines and resources as required, including CMS directives and bulletins.
Collaborate, coordinate, and communicate across disciplines and departments.
Ensure compliance with HIPAA regulations and requirements.
Demonstrate Company's Core Competencies and values held within.
Please note due to the exposure of PHI sensitive data, this role is considered to be a High Risk Role.
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.

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 – accrued based on years of service
WA Candidates: the accrual rate is 4.61 hours every other week for the first two years of tenure before increasing with additional years of service
10 paid company holidays
Tuition reimbursement
Flexible Spending Account
Employee Assistance Program
Sick time benefits – for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year, unless the laws of the state in which the employee is located provide for more generous sick time benefits