Medical Audit Claim Reviewer
3 weeks ago
Job Summary
As a Medical Audit Claim Reviewer, you will play a crucial role in our organization by reviewing and auditing medical claims to ensure compliance with policies, procedures, and regulatory requirements. You will contribute to the accurate and ethical processing of claims, which is essential for the well-being of our members and the financial stability of our organization.
Key Responsibilities/Duties – what you will be doing
- Review and audit medical claims to ensure accuracy, completeness, and compliance with company policies and relevant regulations.
- Examine medical records, bills, and other relevant documentation to validate the appropriateness of the claims submitted.
- Stay up to date with healthcare regulations and industry standards to ensure that all claims meet legal and ethical requirements.
- Verify the medical necessity of procedures, services, and medications, and confirm that they align with the patient's diagnosis.
- Accurately document findings and actions taken during claim reviews in our audit management system.
- Collaborate with healthcare providers, insurance adjusters, and other stakeholders to request additional information, clarify discrepancies, and provide feedback on claim reviews.
- Generate reports and summaries of audit findings to support quality improvement initiatives.
- Participate in ongoing training and professional development to stay current with industry best practices and regulations
- Other projects and duties as assigned.
Qualifications – what you need to perform the job
Education
- Required (minimum): BSN (Bachelor's Science in Nursing)
- Preferred: Master’s degree
Experience (minimum years required):
- Required (minimum): 5-7 years of experience in medical claim auditing, healthcare compliance, or a related role.
- Preferred: 8-10 years of related work experience
Skill Requirements
- Knowledge of medical billing and coding, healthcare regulations, and industry standards.
- Strong analytical and critical thinking skills.
- Excellent attention to detail and the ability to work independently.
- Effective communication and interpersonal skills.
- Proficiency in using relevant software and tools for claim auditing.
- Knowledge of health insurance processes and terminology is a plus.
Commitment to Diversity, Equity & Inclusion
Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
Who We Are
Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
We enjoy the important work we do every day in service to our members, partners, colleagues and communities.
Scam alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org
This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.
Req ID: R8149
-
Medical Audit Claim Reviewer
1 month ago
Canton, United States Point32Health Full timeJob Summary As a Medical Audit Claim Reviewer, you will play a crucial role in our organization by reviewing and auditing medical claims to ensure compliance with policies, procedures, and regulatory requirements. You will contribute to the accurate and ethical processing of claims, which is essential for the well-being of our members and the financial...
-
Medical Audit Claim Reviewer
4 weeks ago
Canton, MA, United States Point32Health Full timeJob Summary As a Medical Audit Claim Reviewer, you will play a crucial role in our organization by reviewing and auditing medical claims to ensure compliance with policies, procedures, and regulatory requirements. You will contribute to the accurate and ethical processing of claims, which is essential for the well-being of our members and the financial...
-
Medical Claims Auditor
1 month ago
Canton, Massachusetts, United States Point32Health Full timeJob SummaryAs a Medical Claims Auditor at Point32Health, you will play a vital role in ensuring the accuracy and integrity of medical claims. Your expertise will be instrumental in maintaining compliance with regulatory requirements and company policies.Key ResponsibilitiesClaim Review and Audit: Conduct thorough reviews of medical claims to ensure accuracy,...
-
Medical Claims Auditor
3 weeks ago
Canton, Massachusetts, United States Point32Health Full timeJob SummaryAs a Medical Audit Claim Reviewer at Point32Health, you will play a critical role in ensuring the accuracy and compliance of medical claims. Your expertise will be essential in maintaining the trust and satisfaction of our members and the financial stability of our organization.Key ResponsibilitiesMedical Claim Review: Conduct thorough reviews of...
-
Medical Claims Auditor
4 weeks ago
Canton, Ohio, United States Point32Health Full timeJob SummaryAs a Medical Audit Claim Reviewer at Point32Health, you will play a critical role in ensuring the accuracy and compliance of medical claims. Your expertise will contribute to the well-being of our members and the financial stability of our organization.Key ResponsibilitiesReview and audit medical claims to ensure accuracy, completeness, and...
-
Life Claims Examiner
1 month ago
Canton, Massachusetts, United States CEI Group LLC Full timeJob SummaryThe Claims Support Specialist will provide timely support to the Claim Services Department, demonstrating exceptional service professionalism in all aspects of the role. This position reports directly to the Supervisor Claim Support and is responsible for ensuring the smooth operation of the claims process.Key ResponsibilitiesClaims Preparation:...
-
Life Claims Examiner
2 months ago
Canton, United States CEI Group Full timeDescription: The role reports directly to the Supervisor Claim Support. The role is responsible for providing timely support to the Claim Services Department while demonstrating the highest levels of service professionalism in all they do. The role is expected to: Prepare items for imaging, including new claims, correspondence, closed claim files, and...
-
Life Claims Examiner
1 week ago
Canton, United States CEI Group Full timeDescription:The role reports directly to the Supervisor Claim Support.The role is responsible for providing timely support to the Claim Services Department while demonstrating the highest levels of service professionalism in all they do.The role is expected to:Prepare items for imaging, including new claims, correspondence, closed claim files, and...
-
Health Claims Examiner
2 weeks ago
Canton, Massachusetts, United States CEI Group Full timeJob Title: Health Claims ExaminerCEI Group is seeking a highly skilled Health Claims Examiner to join our team. As a Health Claims Examiner, you will be responsible for providing timely support to our Claim Services Department while demonstrating the highest levels of service professionalism in all you do.Key Responsibilities:Prepare items for imaging,...
-
RCIS Crop Claims Field Adjuster I
1 week ago
Canton, Ohio, United States Zurich Insurance Company Ltd. Full timeRCIS Crop Claims Field Adjuster IZurich is seeking a highly skilled RCIS Crop Claims Field Adjuster I to join our Rural Community Insurance Services (RCIS) team.As a leading crop insurance provider in the U.S., RCIS offers insurance protection in all 50 states through a national network of about 3,600 licensed agents.We are looking for a talented individual...
-
Health and Disability Claims Examiner
1 month ago
Canton, United States CEI Group LLC Full timeHealth and Disability Claims Examiner Full Job Description: The role reports directly to the Supervisor Claim Support. The role is responsible for providing timely support to the Claim Services Department while demonstrating the highest levels of service professionalism in all they do. MUST HAVE: Direct Life Claims experience. The role is expected to:...
-
Health and Disability Claims Examiner
2 weeks ago
Canton, United States CEI Group Full timeHealth and Disability Claims Examiner Full Job Description: The role reports directly to the Supervisor Claim Support. The role is responsible for providing timely support to the Claim Services Department while demonstrating the highest levels of service professionalism in all they do. MUST HAVE: Direct Life Claims experience. The role is expected...
-
MDS Appeal and Chart Review Specialist
3 weeks ago
Canton, Ohio, United States Altercare Integrated Health Services Full timeAbout the RoleWe are seeking a highly skilled MDS Appeal and Chart Review Specialist to join our team at Altercare Integrated Health Services. As a key member of our healthcare operations team, you will play a critical role in ensuring the accuracy and compliance of our medical records and billing processes.Key ResponsibilitiesRoutine audits of facility PDPM...
-
Health and Disability Claims Examiner
1 month ago
Canton, Massachusetts, United States CEI Group LLC Full timeJob Summary: We are seeking a highly skilled Claims Examiner to join our team at CEI Group LLC. As a Claims Examiner, you will play a critical role in supporting our Claim Services Department by providing timely and professional support.Key Responsibilities:Prepare items for imaging, including new claims, correspondence, closed claim files, and notification...
-
Health and Disability Claims Examiner
1 week ago
Canton, United States CEI Group Full timeHealth and Disability Claims Examiner Full Job Description:The role reports directly to the Supervisor Claim Support. The role is responsible for providing timely support to the Claim Services Department while demonstrating the highest levels of service professionalism in all they do.MUST HAVE: Direct Life Claims experience. The role is expected to:Prepare...
-
Health and Disability Claims Examiner
2 weeks ago
Canton, Massachusetts, United States CEI Group Full timeJob Title: Health and Disability Claims ExaminerWe are seeking a highly skilled and detail-oriented Health and Disability Claims Examiner to join our team at CEI Group.Key Responsibilities:Prepare items for imaging, including new claims, correspondence, closed claim files, and notification of claims.Provide backup support to the data imager.Index relevant...
-
Audit Manager
1 month ago
Canton, United States Spartan Placements LLC Full timeAbout the RoleSpartan Placements LLC is seeking a highly skilled and experienced Audit Senior to join our team. As an Audit Senior, you will play a key role in leading audits, reviews, and compilations, and will be responsible for supervising less experienced staff.Key ResponsibilitiesLead Audits and Reviews: Participate in and assume in-charge...
-
Health and Disability Claims Examiner
1 week ago
Canton, Ohio, United States CEI Group Full timeJob Title: Health and Disability Claims ExaminerAt CEI Group, we are seeking a highly skilled and detail-oriented Health and Disability Claims Examiner to join our team.Key Responsibilities:Provide timely support to the Claim Services DepartmentCollaborate with the Supervisor Claim Support to ensure seamless service deliveryConduct thorough reviews of health...
-
Audit Senior
4 weeks ago
Canton, United States Spartan Placements LLC Full timeSpartan Placements LLC is seeking a highly skilled Audit Senior to join our team. As an Audit Senior, you will be responsible for participating in and assuming in-charge responsibilities for audits, reviews, and compilations. You will also supervise less experienced staff, directly correspond and communicate with clients, and meet due date responsibilities....
-
Audit Supervisor
5 days ago
Canton, Massachusetts, United States CyberCoders Full timePosition OverviewWe are seeking an experienced and highly motivated Audit Supervisor or Manager to oversee the planning and execution of various audit engagements, ensuring compliance with all regulatory requirements and company policies.Key ResponsibilitiesManage audit engagements from start to finish, including planning, fieldwork, reporting, and...
