Medicare Compliance Claim Analyst - Michigan

AAA-The Auto Club Group•Fremont, MI

3d•$24 - $29•Hybrid

About The Position

The Auto Club Group is looking for a detail-oriented and analytical Michigan Medicare Compliance Claims Analyst to play a vital role in ensuring accurate, compliant, and cost-effective medical claims processing. In this dynamic position, you'll leverage web-based technology and specialized applications to review, analyze, document, and manage medical claims while helping deliver exceptional service to members, providers, and internal stakeholders. As a trusted subject matter expert, you'll investigate and evaluate medical billing charges, ensuring treatments and services aligning with claim-related injuries and Medicare compliance requirements. You'll 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 role offers extensive collaboration, as you'll partner 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'll also serve as a key liaison, helping drive positive outcomes through research, problem-solving, and effective communication. Additionally, you'll monitor claim expenditures, approve reasonable and customary payments in accordance with corporate guidelines, support recovery efforts when appropriate, and may represent the organization during depositions, settlement hearings, and other legal proceedings. If you thrive in a fast-paced environment where analytical thinking, compliance expertise, and customer advocacy come together, this is an exciting opportunity to make a meaningful impact while contributing to the financial integrity and service excellence of The Auto Club Group.

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.
claim analysis, or similar function
medical bill review (cost containment)
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
Ability to effectively 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

Nice To Haves

Associate's degree in Business Administration, Insurance or a related field.
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 in order 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, etc.
Assist in the recovery of medical expenditures from the insured, medical providers, etc. in accordance with established procedures if applicable.

Benefits

PTO, paid sick 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
Health Savings Account (HSA) and Flexible Spending Accounts (FSA) options.
Paid Time Off (PTO)
Paid holidays
mental health day
floating holidays
volunteer day
Paid leave programs, including parental, bereavement, jury duty, and military leave.
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.