Medical Claims Auditor I

Carefully examine medical claims documentation, including medical records, bills, and supporting documents, to verify the accuracy and completeness of information submitted by healthcare providers. Apply appropriate coding guidelines (e.g., ICD-10, CPT, HCPCS) to ensure that diagnoses, procedures, and services are correctly coded, in accordance with industry standards and regulatory requirements. Validate the appropriateness of claims based on established policies, contracts, and medical guidelines. Identify any discrepancies or inconsistencies and appropriately communicate them for further investigation. Identify and investigate potential billing errors, such as duplicate claims, unbundling, upcoding, and incorrect coding combinations. Report findings to the Claims Manager or designated supervisor. Monitor claims processing activities to ensure adherence to legal and regulatory requirements, such as HIPAA, CMS guidelines, and contractual obligations. Document audit findings, maintain accurate records, and generate comprehensive reports summarizing audit results, trends, and recommendations for process improvement. Collaborate with internal stakeholders, including claims processors, billing specialists, and healthcare providers, to resolve claim-related issues, provide guidance on coding requirements, and address any questions or concerns. Stay up-to-date with changes in coding guidelines, industry regulations, and best practices. Participate in training sessions and professional development activities to enhance knowledge and skills. Assist in the implementation and maintenance of quality assurance processes to ensure the accuracy, integrity, and efficiency of claims processing operations. Contact providers to obtain additional information and/or documentation to resolve unpaid claims, as directed. Respond to carrier telephone, fax and e-mail inquiries regarding outstanding claims Confer with carriers by telephone or use portals/web sites to determine member eligibility and claim status. Update case management system with proper noting of actions and appeal/denial information. Generate form letters to carriers to affect payment of outstanding claims. Leverage RCM knowledge to assess denials, pursue appeals or close claims when appropriate. Work with document imaging system for processing purposes. Responsible for achieving high recoveries against a portfolio of claims. Responsible for achieving daily, monthly, and quarterly quality and productivity KPIs. Non-Essential Responsibilities Performs other functions as assigned Knowledge, Skills and Abilities Proven experience in medical claims processing, medical billing, or coding, preferably in an auditing capacity. Strong understanding of third-party billing and/or claims processing. Strong knowledge of medical terminology, anatomy, physiology, and ICD-10, CPT, and HCPCS coding systems. Familiarity with healthcare regulations, including HIPAA, CMS guidelines, and insurance policies. Proficient in using medical billing software and coding databases. Excellent analytical and problem-solving skills with a keen attention to detail. Effective communication skills, both verbal and written, to interact with internal teams and external stakeholders. Ability to work independently, prioritize tasks, and meet deadlines. Strong ethical standards and understanding of confidentiality requirements. Continuous learning mindset and willingness to stay updated with industry changes. Ability to perform basic mathematic calculations. Ability to work proficiently with Microsoft Windows, Word and have intermediate level knowledge of Excel. Average manual dexterity in use of a PC, phone, sorting, filing and other office machines. Ability to perform well in team environment, with staff at all levels, to achieve business goals. Possess excellent customer service skills. Ability to work independently to meet predefined production and quality standards. Work Conditions and Physical Demands Primarily sedentary work in a general office environment Ability to communicate and exchange information Ability to comprehend and interpret documents and data Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.) Requires manual dexterity to use computer, telephone and peripherals May be required to work extended hours for special business needs May be required to travel at least 10% of time based on business needs Minimum Education High School Diploma or equivalent required. Some college coursework (with concentration in healthcare, medical billing or coding field) or a degree in a related field is preferred. Associates Degree Preferred. Certifications (Required/Desired) Certification in medical billing/coding (e.g., CPC, CCS) is preferred Minimum Related Work Experience 5-7 yrs. experience with third party collections 3yr experience handling appeals claims in hospital setting, Ability to interpret an Explanation of Benefits (EOB) and UB-04 claim form required. DSM-IV, CPT, HCPCS, and CMS-1500 preferred Working knowledge of Access and SQL also preferred