Medical Claims Auditor II

We are seeking a talented individual for a Medical Claims Auditor II who performs research analytics to support our Coordination of Benefits line of business. Assists in the development and implementation of new claim follow up processes for identifying claims that are denied incorrectly.We are seeking a talented individual for a Medical Claims Auditor II who performs research analytics to support our Coordination of Benefits line of business. Assists in the development and implementation of new claim follow up processes for identifying claims that are denied incorrectly.Essential Responsibilities:• Participates in the review of health insurance claims and member eligibility information to perform root cause analysis on misapplication of payment policies, medical policies, billing guidelines, and applicable regulatory requirements. • Tracks, and follows-up on results and recoveries• Contributes new ideas for improving existing processes. Works cohesively with IT, operations, carriers, and clients. • Develops, maintains, and ensures adherence to multiple project schedulesEssential Responsibilities:• Participates in the review of health insurance claims and member eligibility information to perform root cause analysis on misapplication of payment policies, medical policies, billing guidelines, and applicable regulatory requirements. • Tracks, and follows-up on results and recoveries• Contributes new ideas for improving existing processes. Works cohesively with IT, operations, carriers, and clients. • Develops, maintains, and ensures adherence to multiple project schedulesKnowledge, Skills and Abilities:• Strong Conceptual and analytical skills• In depth knowledge of UB04 (institutional) and medical 1500 (professional) claim formats and requirements.• In depth knowledge of coding principals including but not limited to NCCI Edits, CPT, HCPCS and ICD-9 codes and modifiers, and revenue codes• Good understanding of Medicaid required, Medicare and commercial experience a plus.• Sound understanding of medical terminology and anatomy.• Ability to develop, organize, and maintain project plans and agendas• Working knowledge of Microsoft Suite of products (Excel, Word, Access)• Strong Project management skillsKnowledge, Skills and Abilities:• Strong Conceptual and analytical skills• In depth knowledge of UB04 (institutional) and medical 1500 (professional) claim formats and requirements.• In depth knowledge of coding principals including but not limited to NCCI Edits, CPT, HCPCS and ICD-9 codes and modifiers, and revenue codes• Good understanding of Medicaid required, Medicare and commercial experience a plus.• Sound understanding of medical terminology and anatomy.• Ability to develop, organize, and maintain project plans and agendas• Working knowledge of Microsoft Suite of products (Excel, Word, Access)• Strong Project management skillsMinimum 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, and/or revenue cycle improvement required.Minimum 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, and/or revenue cycle improvement required.Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-9-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 preferred.Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-9-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 preferred.Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data, Recovery audit experience a plus preferred