Medical Claims Auditor

3 weeks ago

Franklin, United States inAssist Health Management Solutions Full time

HealthLock (inAssist) Medical Claims Auditor / Advocate II


HealthLock (inAssist) is a leading provider of Healthcare Management Solutions, utilizing our Medical Claims Auditors / Advocates, comprehensive analytics, and tailored technology solutions. Driven by our commitment to our clients, we take pride in delivering exceptional service.


The Medical Claims Auditor / Advocate II reviews complex healthcare claims to identify discrepancies, verify pricing, confirm prior authorizations and benefits in an effort to reduce members’ out of pocket healthcare costs. You’ll need to be comfortable navigating multiple computer systems to find critical information as well as maximize your knowledge of the healthcare system. Critical thinking and attention to detail is crucial for accurate and timely case resolution.


Job Role:

  • Review patient medical bills, correspondence, and Explanation of Benefits (EOBs) for errors.
  • Liaise with insurance carriers and providers to address identified issues (e.g., appeal incorrectly denied claims, rectify billing errors, negotiate with providers regarding inappropriate billing).
  • Communicate with providers and carriers via phone and email, ensuring prompt and professional responses, and going above and beyond to address concerns, making medical bills and paperwork a worry-free experience.
  • Identify problems and inconsistencies using management reports and critical thinking skills.
  • Utilize expertise and take initiative to resolve claims/billing issues.
  • Review EOBs and examine claims for appropriate coding of CPT and ICD-9 and -10 codes and modifiers against charges that are billed.
  • Apply appropriate processes and procedures for medical claims (e.g., claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/certificates).
  • Review and apply member benefit plans and provider contracts, pricing, CMS rate letter, SCA’s etc. to ensure proper benefits and contract language is applied to each claim.


Job Requirements:

  • Background in medical billing or insurance claims administration (Medical Billing, Coding and Collections Specialists, and/or Health Insurance Claims Administrators strongly preferred).
  • 3-5+ years’ experience in Medical Billing and Coding.
  • Strong critical thinking and problem-solving skills.
  • Proficiency in Explanation of Benefits (EOB) knowledge.
  • Strong interpersonal skills.
  • Self-motivated and reliable.
  • Proven exceptional ability to organize, prioritize and communicate effectively with carriers and providers.
  • Experience with Out of Network (OON) Benefits is advantageous.
  • Understanding of general Coordination of Benefit Rules, Benefit Analysis.
  • Knowledge of eligibility requirements and insurance enrollment.
  • Experience in overturning claim denials, from simple solutions like coding correction to more complex appeals and grievances.
  • Communicate and collaborate with external stakeholders (e.g., members, family members, providers, vendors) to resolve claim errors/issues, using clear, simple language to ensure understanding.
  • Excellent time-management and deadline management skills.
  • Ability to multitask with a sense of urgency.
  • Knowledge of CPT/ICD-9 and -10 required. Medical Billing and/or Coding Certificate a plus.
  • Website navigation proficiency of carrier web portals for resolution and/or claim processing.
  • Experience in investigating and researching appeals and drug manufacturer websites for copay assistance.
  • Support implementation of updates to the current procedures and participate in new system updates and training.
  • Excellent organizational and scheduling abilities.
  • Proficiency with Microsoft Office Suite (Outlook, Word, Excel etc.)


Benefits you will enjoy when you join our team:

  • Extensive paid training.
  • Supportive team environment and advancement opportunities.
  • Comprehensive benefits, including medical, dental, vision, 401K, and life insurance.
  • Generous PTO and paid Holidays.


Join a rapidly growing and dynamic healthcare company

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