Medicare Compliance Claim Analyst - Michigan

Auto Club Group•Auburn Hills, MI

1d•Hybrid

About The Position

The Auto Club Group is seeking a detail-oriented and analytical Medicare Compliance Claims Analyst to ensure accurate, compliant, and cost-effective medical claims processing. This role involves leveraging web-based technology and specialized applications to review, analyze, document, and manage medical claims, while providing exceptional service to members, providers, and internal stakeholders. As a subject matter expert, you will investigate and evaluate medical billing charges, ensuring treatments and services align with claim-related injuries and Medicare compliance requirements. You will analyze medical records, explanation of benefits (EOBs), loss reports, and other documentation to make informed payment decisions and identify opportunities to prevent duplicate or inappropriate payments. This position requires extensive collaboration with claim representatives, medical professionals, healthcare providers, and customers to resolve billing inquiries, explain payment determinations, verify coverage, coordinate benefits, and ensure proper billing practices. You will also monitor claim expenditures, approve reasonable and customary payments, support recovery efforts, and may represent the organization in legal proceedings. This role is ideal for individuals who thrive in a fast-paced environment requiring analytical thinking, compliance expertise, and customer advocacy.

Requirements

College level coursework in Business Administration, Insurance, Management, or a related field.
A valid driver's license is required if the primary responsibilities of the role involve conducting in-person inspections or frequent in-person meetings with members.
Experience in claim analysis, or similar function medical bill review (cost containment).
Experience operating a personal computer utilizing software packages (e.g. Word, Excel, Access, Power Point, VISIO, etc.).
Knowledge of one or more of the following: medical terminology and human anatomy, CPT, ICD-9 and 10 and revenue codes (MBRU), Property and casualty claim process and procedures, FACTS, IPM and CPS.
Ability to use automated processing systems effectively.
Ability to respond to questions/concerns.
Ability to communicate effectively with others in a work environment, with the Public and vendors.
Ability to independently perform detailed, complex medical bill or similar analysis.
Demonstrated skill in organization and planning.
Demonstrated skill in analyzing and problem solving.
Demonstrated skill in written communications to include record keeping and report preparation.
Demonstrated skill in decision making.
Demonstrated skill in negotiating.
Candidates must reside within the state of Michigan for hybrid purposes.

Nice To Haves

Associate's degree in Business Administration, Insurance or a related field.
Experience processing or working within a medical claims environment.
Medical billing experience with both Medicare and Medicaid.
Exposure to processing or working with VA (Veteran Affairs) claims.
Working within a heavy team environment.
Performing both inbound and outbound calling to internal and external clients.
The ability to communicate proficiently both orally and written.
The ability to remain organized and work on multiple tasks simultaneously and efficiently.
The ability to work independently on a remote basis and be self-sufficient within a professional setting.

Responsibilities

Review claim information to determine if ACG has an exposure of ORM.
Process Medicare Advantage requests for reimbursement.
Identify proper data if claim qualifies for reporting, if not remove from reporting.
Report on appropriate claims.
Determine validity of CMS liens.
Act as a liaison between the customer and providers to research payment status, explain payment amounts approved, resolve lower-level reconsiderations, verify coverage, explain coordination of benefits pre-authorization and correct billing procedures to providers.
Assist in the recovery of medical expenditures from the insured, medical providers, etc. in accordance with established procedures if applicable.

Benefits

Paid Time Off (PTO)
Paid holidays
Mental health day
Floating holidays
Volunteer day
Parental leave
Bereavement leave
Jury duty leave
Military leave
Medical plans with multiple coverage options, including HSA eligibility.
Prescription drug coverage.
Dental and vision benefits.
Employee Assistance Program (confidential support services).
Company-paid basic life insurance.
Optional supplemental life insurance and dependent coverage.
Short-term and long-term disability coverage.
Critical illness, accident, and pet insurance options.
401(k) plan
Company match of 50% paid on employee contributions up to 6% of pay, payable to employees following the end of the year; immediate vesting.
Additional company contribution of 4% of pay each pay day into your account; 100% vested after three (3) years of service.
Health Savings Account (HSA) and Flexible Spending Accounts (FSA) options.
Tuition assistance (up to $5,250 annually; 80% covered by ACG).
Professional certification support with 100% reimbursement for eligible programs.
Opportunities for career development and advancement.
Complimentary AAA membership with roadside assistance and travel discounts.
Adoption assistance program.
Annual company bonus incentive.