Medical Claims Auditor

Description :

• 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

Knowledge, Skills and Abilities

Work Conditions and Physical Demands

Minimum Education

Certifications (Required / Desired)

Minimum Related Work Experience