Claims Auditor, Health Plan

This is a fully remote position, open to applicants in Wisconsin.

📋 Description

• Accountable for conducting audits on claims regarding payment, procedural accuracy, turnaround time, compliance, and operations as instructed by management.

• Implement effective, suitable, and efficient auditing procedures to gather, analyze, and deliver clear and pertinent findings.

• Create and sustain a comprehensive understanding of CPT coding guidelines, ICD codes, healthcare common procedure coding system (HCPCS) codes, modifiers, documentation guidelines, CMS policies, Medicaid regulations, and other reimbursement standards to assess claims for accuracy, compliance, proper billing, and adherence to insurance policies and regulations.

• Investigate discrepancies in claims and report them to the appropriate personnel for rectification.

• Perform monthly audits of pre-pay and post-paid claims to validate the precision of processing, financials, procedures, and turnaround times.

• Examine medical records to ascertain the legitimacy of medical charges on claims selected for detailed audit review.

• Analyze and resolve intricate claim processing issues, ensuring prompt resolution of queries, audits, or system challenges.

• Evaluate claim errors and provide reports to management to enhance processes, editing, or claim workflows.

⛳️ Requirements

• High school diploma or equivalent is required.

• Successful completion of departmental courses within one year of hire is mandatory: current procedural terminology (CPT), current international classification of diseases (ICD), health care procedure coding system (HCPCS), and medical terminology.

• An Associate's degree in business, medical, or a related field is preferred.

• A minimum of three years of experience related to health insurance claim processing is required.

• At least three years of experience pertinent to CPT/HCPCS and current ICD coding.

• Proven expertise in analytical problem-solving, written and verbal communication, and proficiency in the Microsoft Office Suite.

• Familiarity with anatomy & physiology is essential.

• One year of experience in claims auditing is preferred.

• Certification as a Certified Professional Coder (CPC) or Certified Professional Coder – Payer (CPC-P) from the American Academy of Professional Coders (AAPC) at the time of hire is preferred.

🏝️ Benefits

• Flexible scheduling options.

• Remote work.