Healthcare Claims Auditor

1 week ago

Columbus, Ohio, United States inAssist Full time
Job Overview

Position: Healthcare Claims Auditor / Advocate II

inAssist is a prominent provider of Healthcare Management Solutions, leveraging our Medical Claims Auditors / Advocates, advanced analytics, and customized technology solutions. Our dedication to our clients drives us to deliver outstanding service.

The Healthcare Claims Auditor / Advocate II is responsible for examining intricate healthcare claims to pinpoint discrepancies, validate pricing, and confirm prior authorizations and benefits, all aimed at minimizing members' out-of-pocket healthcare expenses. Proficiency in navigating various computer systems to retrieve essential information and a deep understanding of the healthcare system are vital. Critical thinking and meticulous attention to detail are essential for precise and timely case resolution.

Key Responsibilities:

  • Scrutinize patient medical bills, correspondence, and Explanation of Benefits (EOBs) for inaccuracies.
  • Collaborate with insurance carriers and providers to resolve identified issues (e.g., appeal wrongly denied claims, correct billing errors, negotiate with providers regarding inappropriate billing).
  • Engage with providers and carriers through phone and email, ensuring prompt and professional communication, and striving to make medical bills and paperwork a hassle-free experience.
  • Detect problems and inconsistencies utilizing management reports and analytical skills.
  • Leverage expertise and take initiative to resolve claims and billing issues.
  • Review EOBs and assess claims for correct coding of CPT and ICD-9 and -10 codes and modifiers against billed charges.
  • Implement appropriate processes and procedures for medical claims (e.g., claims processing policies, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents).
  • Analyze member benefit plans and provider contracts, pricing, CMS rate letters, and other relevant documents to ensure accurate application of benefits and contract language to each claim.

Qualifications:

  • Experience in medical billing or insurance claims administration (Medical Billing, Coding and Collections Specialists, and/or Health Insurance Claims Administrators preferred).
  • 3-5+ years of experience in Medical Billing and Coding.
  • Strong critical thinking and problem-solving abilities.
  • Proficient in Explanation of Benefits (EOB) knowledge.
  • Excellent interpersonal skills.
  • Self-driven and dependable.
  • Proven ability to organize, prioritize, and communicate effectively with carriers and providers.
  • Familiarity with Out of Network (OON) Benefits is a plus.
  • Understanding of general Coordination of Benefit Rules and Benefit Analysis.
  • Knowledge of eligibility requirements and insurance enrollment.
  • Experience in overturning claim denials, from simple coding corrections 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 and simple language to ensure understanding.
  • Exceptional time-management and deadline management skills.
  • Ability to multitask with a sense of urgency.
  • Knowledge of CPT/ICD-9 and -10 is required. Medical Billing and/or Coding Certificate is a plus.
  • Proficiency in navigating carrier web portals for resolution and/or claim processing.
  • Experience in investigating and researching appeals and drug manufacturer websites for copay assistance.
  • Support the implementation of updates to current procedures and participate in new system updates and training.
  • Excellent organizational and scheduling skills.
  • Proficient with Microsoft Office Suite (Outlook, Word, Excel, etc.).

Benefits:

  • Comprehensive paid training.
  • Supportive team environment with opportunities for advancement.
  • Extensive benefits package, including medical, dental, vision, 401K, and life insurance.
  • Generous paid time off and holidays.

Join a rapidly expanding and dynamic healthcare organization.

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