Claim Auditor

Primarily responsible for thorough review of managed care contracts and comparison of such contracts against healthcare claims to identify underpayments for the assigned client.

Duties and Responsibilities

• Research commercial and governmental payor policies, clinical abstracts and studies, and other documentation related to claims payment to evaluate and appeal denied claims

• Examine claims and calculate reimbursement based on contract terms to determine accuracy of payment through use of various reports and supporting documentation

• Review insurance contracts to gain thorough understanding of payment methodologies

• Contact insurance company to obtain missing information, explain and resolve denials and arrange for payment or adjustment processing on behalf of client

• Follow up on claims in a timely fashion as outlined in Company and/or departmental policies and procedures

• Document information in appropriate company and client systems

• Prepare and submit correspondence such as letters, emails, online inquiries, appeals, adjustments, reports and payment posting

• Maintain regular contact with necessary parties regarding claims status including payors, clients, managers, and other Company personnel

• Communicate with client contact concerning all issues related to billing, posting, contracts and all other client related issues, both in an informal manner through daily contact and formal manner through scheduled meetings

• Promotes positive public relations for Company, including maintaining a professional attitude and approach with all payors

• Build strong, lasting relationships with clients, payors and company personnel

• Support and direct claims to all company departments and client onsite analysts

• Attend client, department and company meetings

• Comply with federal and state laws, company policies and procedures

• All other duties as assigned

Skills and Experience

• Minimum 3 years of insurance billing, denial management and/or utilization review experience

• Experience reviewing and analyzing hospital claims

• Knowledge of healthcare codes including CPT, ICD-9, ICD-10, HCPC, DRG, and ability to correctly use and apply codes in operational setting

• High school diploma or equivalent

• Microsoft Excel, Outlook, Word

• Moderate computer proficiency

• Mathematical skills: ability to calculate rates using addition, subtraction, multiplication and division

• Ability to read and interpret an extensive variety of documents such as contracts, claims, instructions, policies and procedures in written (in English) and diagram form

• Ability to write routine correspondence (in English)

• Ability to define problems, collect data, establish facts and draw valid conclusions

• Strong customer service orientation

• Excellent interpersonal and communication skills

• Strong team player

• Commitment to company values