Medical Claims Investigator

Job Summary

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.

Job Roles And 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.

Job Scope

This role keeps the needs of external and internal customers as a priority when making decisions and taking action. Will work under direct supervision to uncover actionable claims which facilitate savings for customers. Interacts with customers and internal staff in the organization.

Compensation

• The salary range for this position is $50-55K.
• Specific offers take into account a candidate's education, experience and skills, as well as the candidate's work location and internal equity.
• This position is also eligible for health insurance, 401k and bonus opportunity.

Job Requirements (Education, Experience, And Training)

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

Job 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.
• 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.

EEO Statement

Claritev is an Equal Opportunity Employer and complies with all applicable laws and regulations. Qualified applicants will receive consideration for employment without regard to age, race, color, religion, gender, sexual orientation, gender identity, national origin, disability or protected veteran status.