Medical Claims Investigator

Imagine a workplace that encourages you to interpret, innovate and inspire. Our employees do just that by helping healthcare payers manage the cost of care, improve competitiveness and inspire positive change. You can be part of an established company with a 40-year legacy that helps our customers thrive by interpreting our client's needs and tailoring innovative healthcare cost management solutions.

Our commitment to diversity, inclusion and belonging are part of the fabric of our company. We strive to create a workplace that fosters mutual respect and collaboration, where every talent individual can participate and perform their best work. We are MultiPlan and we are where bright people come to shine!

JOB SUMMARY:

This role reviews medical paid claims against provider contracts and policies to ensure medical payments have been processed accurately. The incumbent will employ data mining and coordination of benefit techniques to analyze and audit hospital and physician claims to identify errant claim payments.

JOB ROLES AND RESPONSIBILITIES:

1. Achieve measured production, quality, and growth results.
2. Utilize analytics and data mining and coordination of benefits techniques to client paid claims data.
3. Evaluate medical claims for coding and pricing errors using accurate HCPCS, ICD-10, and CPT codes.
4. Lookup and review medical claims in payer system to determine methods of payment and validate savings identified.
5. Promote a positive team environment that is based around critical thinking and sharing intelligence to help meet both individual and team goals.
6. Utilize official coding guidelines and resources as required, including CMS directives and bulletins.
7. Collaborate, coordinate, and communicate across disciplines and departments.
8. Ensure compliance with HIPAA regulations and requirements.
9. Demonstrate Company's Core Competencies and values held within.
10. Please note due to the exposure of PHI sensitive data, this role is considered to be a High Risk Role.
11. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

JOB SCOPE:

This role keeps the needs of external and internal customers as a priority when making decisions and taking action. Will work under direct supervision to uncover actionable claims which facilitate savings for customers. Interacts with customers and internal staff in the organization.