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Medical Claims Auditor
2 months ago
As 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 Responsibilities- Claim Review and Audit: Conduct thorough reviews of medical claims to ensure accuracy, completeness, and compliance with company policies and regulations.
- Medical Record Analysis: Examine medical records, bills, and other relevant documentation to validate the appropriateness of claims submitted.
- Regulatory Compliance: Stay up-to-date with healthcare regulations and industry standards to ensure that all claims meet legal and ethical requirements.
- Medical Necessity Verification: Verify the medical necessity of procedures, services, and medications, and confirm that they align with the patient's diagnosis.
- Documentation and Reporting: Accurately document findings and actions taken during claim reviews in our audit management system.
- Collaboration and Communication: Collaborate with healthcare providers, insurance adjusters, and other stakeholders to request additional information, clarify discrepancies, and provide feedback on claim reviews.
- Quality Improvement: Generate reports and summaries of audit findings to support quality improvement initiatives.
- Professional Development: Participate in ongoing training and professional development to stay current with industry best practices and regulations.
- Education: Bachelor's Science in Nursing (BSN) or a related field.
- Experience: 5-7 years of experience in medical claim auditing, healthcare compliance, or a related role.
- 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; effective communication and interpersonal skills; proficiency in using relevant software and tools for claim auditing.
