Senior Claims Auditor
1 month ago
Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.
Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.
We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.
Under the general direction of the Manager of Payment Integrity, the Sr. Claims Auditor performs accurate and timely reviews of medical claims for internal audits. The Sr. Claims Auditor reviews detailed medical claims data, medical records, reference materials, provider contracts, medical policies, and payment policies. The Sr. Claims Auditor will be the primary point of contact for issue resolution regarding internal audits between Mass General Brigham Health Plan and the provider community, as well as for coding knowledge within the Provider Audit team. Additionally, the Senior Claims Auditor will assist in preparing audit reports, including vendor and project summaries.
Principal Duties and Responsibilities:
The Sr. Claims Auditor utilizes CPT and ICD-10 coding to review physician claims and medical records for coding accuracy.
Internal auditing functions focus on "desktop reviews" of claims, design and quality control of future audits, and other auditing related functions.
Review clinical notes and claims submitted to verify the appropriateness of codes billed based on services documented / rendered for both institutional and professional claims. Provides timely claims payment decisions based on review.
Work cooperatively with other departments to obtain required documentation to complete clinical notes review.
Communicate with hospital or provider staff regarding correct coding where inconsistencies in documentation for services provided are identified. Work with Provider Audit Manager for formal correspondence to providers.
Review and analyze facility and professional claims against MGBHP's policies and CMS guidelines. Apply knowledge and experience during decision-making process. Complete and document audits based on established guidelines.
Identify and provide analytical data on billing trends/issues for potential areas of recoveries.
Lead department efforts to select and implement new claims edits created by software and vendors. Analyze results from editing software and offer recommendations for changing rules.
Regularly reviews to identify enhancement to the audit methodology and documentation requirements.
Serves as a coding resource for the Provider Audit team and other departments to interpret and explain coding guidelines as needed.
Support internal customers by answering questions about policies/guidelines.
Provide input on and research of claims challenged by the providers.
Works with Manager of Payment Integrity to develop and implement selection methodology and assist testing new prepay audit implementations.
Assist with selection of audit criteria based on historical findings or new coding rules. Assist with the assignment and pricing of unlisted codes, and Audit related appeals. Regularly review to identify enhancement to the audit methodology and documentation requirements.
Identify potential audit concepts and notify Manager of Payment Integrity of any leads, in support of next steps or escalation to outside agencies.
Serves as a coding resource for the Provider Audit team and other departments to interpret and explain coding guidelines as needed.
Work with other departments to obtain required documentation to complete medical records review.
Other duties as assigned with or without accommodation.
Qualifications
Qualifications:
Required to possess Certified Professional Coder (CPC) certification or CCS (Certified Coding Specialist)
2+ years of direct auditing experience in a Managed Care environment
High School diploma required. Associates or Bachelors degree preferred or the equivalent combination of training and experience, plus 3-5 years of related experience
4+ of coding experience in Managed Care, medical billing, facility or physician environment required.
2+ years of direct auditing experience in a Managed Care environment
Thorough knowledge of ICD-10, CPT, HCPS, and Revenue Billing Codes.
Ability to write clearly and succinctly in a variety of communication settings and style
Excellent communication and presentation skills across various levels and through multiple channels (oral, written, conversational)
Strong quantitative and analytical skill
Ability to apply expertise in various training formats.
EEO Statement
Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
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