Medical Claims Auditor II - CSI

The Medical Claims Auditor II performs research analytics to support our recovery audit line of business. Assists in the development and implementation of new data mining and audit/review methodologies for identifying healthcare overpayments and underpayments to providers, and the detection of healthcare fraud, waste, and abuse. Our Medical Claims Auditors also organize, negotiate, and communicate claim denials to the clinical staff and the CSI department, as well as our carrier representatives. The Medical Claims Auditor II performs research analytics to support our recovery audit line of business. Assists in the development and implementation of new data mining and audit/review methodologies for identifying healthcare overpayments and underpayments to providers, and the detection of healthcare fraud, waste, and abuse. Our Medical Claims Auditors also organize, negotiate, and communicate claim denials to the clinical staff and the CSI department, as well as our carrier representatives.Essential Responsibilities:• Participates in the review of health insurance claims and member eligibility information to uncover claims trends associated with non-compliance or misapplication of contract terms and rates, payment policies, medical policies, coding guidelines, billing guidelines, and applicable regulatory requirements. Applies knowledge of provider billing and patient accounting practices to research client policy and data to reveal new payment recovery opportunities. Works with data miners, clinical staff, and stakeholders to identify new improper payment issues for each client.• Review and analysis of denials• Submits, tracks, and follows-up on results and recoveries• Contributes new ideas for improving existing audit processes and audit queries. Works cohesively with the audit team.• Develops, maintains, and ensures adherence to multiple project schedules• Assists in writing professional appeal letters• Provides reporting & education on findings and additional opportunitiesEssential Responsibilities:• Participates in the review of health insurance claims and member eligibility information to uncover claims trends associated with non-compliance or misapplication of contract terms and rates, payment policies, medical policies, coding guidelines, billing guidelines, and applicable regulatory requirements. Applies knowledge of provider billing and patient accounting practices to research client policy and data to reveal new payment recovery opportunities. Works with data miners, clinical staff, and stakeholders to identify new improper payment issues for each client.• Review and analysis of denials• Submits, tracks, and follows-up on results and recoveries• Contributes new ideas for improving existing audit processes and audit queries. Works cohesively with the audit team.• Develops, maintains, and ensures adherence to multiple project schedules• Assists in writing professional appeal letters• Provides reporting & education on findings and additional opportunitiesKnowledge, Skills and Abilities:• Strong Conceptual and analytical skills• Strong Project management skills• Ability to develop, organize, and maintain project plans and agendas• Ability to effectively interface with clients on the phone and in person• Working knowledge of Microsoft Suite of products (Excel, Word, Access)• Sound understanding of medical terminology, anatomy, insurance adjudication processes and terms.• Good understanding of Medicaid required, Medicare and commercial experience a plus.• In depth knowledge of coding principals including but not limited to NCCI Edits, CPT, HCPCS and ICD-10 codes and modifiers; and/or MSDRG, Revenue codes, and APCs as well as DSM-5 codes.• In depth knowledge of UB04 and medical (1500) claim formats and requirements.Knowledge, Skills and Abilities:• Strong Conceptual and analytical skills• Strong Project management skills• Ability to develop, organize, and maintain project plans and agendas• Ability to effectively interface with clients on the phone and in person• Working knowledge of Microsoft Suite of products (Excel, Word, Access)• Sound understanding of medical terminology, anatomy, insurance adjudication processes and terms.• Good understanding of Medicaid required, Medicare and commercial experience a plus.• In depth knowledge of coding principals including but not limited to NCCI Edits, CPT, HCPCS and ICD-10 codes and modifiers; and/or MSDRG, Revenue codes, and APCs as well as DSM-5 codes.• In depth knowledge of UB04 and medical (1500) claim formats and requirements.Minimum Education:High school diploma or GED required; Bachelor's degree preferredMinimum Education:High school diploma or GED required; Bachelor's degree preferredMinimum Related Work Experience:1-3 years of healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, case management, and/or revenue cycle improvement required.Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-10-CM codes, HCPCS codes, CPT codes, DRGs, physician billing, etc. preferred.Experience in healthcare auditing, reviewing and validating the accuracy of claims data and accuracy of claims payment required.Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data, recovery audit experience a plus preferredMinimum Related Work Experience:1-3 years of healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, case management, and/or revenue cycle improvement required.Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-10-CM codes, HCPCS codes, CPT codes, DRGs, physician billing, etc. preferred.Experience in healthcare auditing, reviewing and validating the accuracy of claims data and accuracy of claims payment required.Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data, recovery audit experience a plus preferred• Performs other functions as assigned