Medical Claims Investigator

Role OverviewThis 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.What You Will DoUtilize analytics and data mining and coordination of benefits techniques to client paid claims data, evaluate medical claims for coding and pricing errors, and promote a positive team environment.Why It Might Be a FitThis role is a great fit for individuals with experience in medical claims investigation or data mining / coordination of benefits auditing, knowledge of coding type edits and medical claim reimbursement structures, and proficiency with medical terminology and automated medical claims payment systems.RequirementsMinimum high school diploma or GEDTwo (2) years of direct experience in medical claims investigation or data mining / coordination of benefits auditingRelevant medical billing and coding certificationBachelor's degree in a relevant fieldKnowledge of coding type edits and medical claim reimbursement structures and methodologiesProficiency with medical terminology, medical procedures, medical conditions, and illness and treatment practicesExperience in applying principles of coding guidelines; federal/state regulations and policies pertaining to coding and billingKnowledge in researching state and federal healthcare guidelines, i.e. Medicare and State Medicaid ProgramsFamiliarity with automated medical claims payment systems and/or working knowledge of payer systemsAdvanced computer skills and proficiency with Microsoft ExcelBenefitsMedical, dental and vision coverage with low deductible & copayLife insuranceShort and long-term disabilityPaid Parental Leave401(k) + matchEmployee Stock Purchase PlanGenerous Paid Time OffTuition reimbursementFlexible Spending AccountEmployee Assistance ProgramSick time benefitsOriginally posted on Himalayas