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