Medical Claims Auditor

2 weeks ago


Canton, Ohio, United States Point32Health Full time
Job Summary

As 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 Responsibilities
  • Review and audit medical claims to ensure accuracy, completeness, and compliance with company policies and regulations.
  • Examine medical records, bills, and documentation to validate the appropriateness of claims.
  • Stay up-to-date with healthcare regulations and industry standards to ensure compliance.
  • Verify medical necessity and confirm alignment with patient diagnosis.
  • Document findings and actions taken during claim reviews.
  • Collaborate with healthcare providers, insurance adjusters, and stakeholders to request information and provide feedback.
  • Generate reports and summaries of audit findings to support quality improvement initiatives.
Qualifications
  • Education: BSN (Bachelor's Science in Nursing) required; Master's degree preferred.
  • Experience: 5-7 years of experience in medical claim auditing, healthcare compliance, or a related role required; 8-10 years preferred.
  • Skill Requirements: Knowledge of medical billing and coding, healthcare regulations, and industry standards; strong analytical and critical thinking skills; excellent attention to detail and ability to work independently.
About Point32Health

Point32Health is a leading health and wellbeing organization delivering personalized healthcare experiences to our communities. We leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools.

We are committed to diversity, equity, and inclusion and welcome all applicants 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.



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