Senior Medical Claims Investigator

Claritev•New York, NY

8h•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. The incumbent will assist department leadership in managing productivity and achieving quality and revenue goals as well as mentoring more junior department team members when appropriate.

Requirements

Minimum high school diploma or GED along with four (4) years of direct experience in medical claims investigation or data mining / coordination of benefits auditing.
Advanced knowledge of coding type edits and medical claim reimbursement structures and methodologies.
Advanced proficiency with medical terminology, medical procedures, medical conditions, and illness and treatment practices.
Expertise in COB NAIC Guidelines.
Extensive experience in applying principles of coding guidelines; federal/state regulations and policies pertaining to coding and billing.
Subject matter expert in reviewing and interpreting medium to complex medical contracts.
Experience providing guidance to other employees on coding regulations and reimbursement structures.
Extensive knowledge in researching state and federal healthcare guidelines, including Medicare and State Medicaid Programs.
Familiarity with automated medical claims payment systems and/or working knowledge of payer systems such as Facets and QNXT.
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 monitors 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 bachelor’s degree in a relevant field are both highly preferred.

Responsibilities

Achieve measured production, quality, and growth results.
Utilize analytics, data mining and coordination of benefit techniques to client paid claims data, develop creative and innovative algorithms and queries that facilitate identification of new savings opportunities.
Evaluate medical claims for coding and pricing errors using accurate HCPCS, ICD-10, and CPT codes.
Research coding rules and guidelines in support of internal and external pre-pay edits.
Lookup and review medical claims in payer system to determine methods of payment and validate savings identified.
Provide coding expertise on reimbursement policy, provider contractor investigations, and prepay editing topics.
Represent team in payment policy discussions and when necessary, and document new policies or modifications to existing policies.
Act as a subject matter expert using internal and external tools in order to complete audits and provide guidance to team members.
Aid in the training and peer review of others in the department for data mining / coordination of benefits and auditing best practices.
Act as a mentor by answering questions regarding contracts, policies, and medical coding.
Assist in provider collection efforts and appeal resolution as needed.
Prepare comprehensive overpayment white papers and present to client.
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

health insurance
401k
bonus opportunity
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