Claims Auditor, Reviewer, Coder

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

📋 Description

• Assist in the development and execution of the Quality Assurance Plan for the WTC Health Program, which includes the formulation and implementation of the Audit Plan.

• Utilize the WTC Health Program administrative manual, medical benefit plan resources, and other relevant Program guidance to facilitate claims review, auditing activities, prior authorization recommendations, and policy interpretation.

• Act as a specialist for the Program regarding claims processing and formal evaluations (audits); support Program claims reviews (audits) in alignment with industry standards and the WTC Health Program's policies and procedures.

• Conduct research and evaluations of federal payer coverage determinations and administrative/clinical activities to develop policies and procedures that are comprehensive and aligned with Program requirements.

• Analyze raw claims data to independently identify issues, patterns, and trends, making final recommendations to the WTC Health Program regarding the appropriateness of services within treatment/benefit plans, leveraging expertise in health insurance reimbursement and medical coding/claims.

• Assist in managing and maintaining the Program’s health plan codebook, recommend code additions, and review claims to ensure correct application of ICD, HCPCS, CPT, and DRG codes.

• Stay informed about coding conventions, evidence-based practices, and federal payer policies.

• Continuously evaluate and engage with industry changes and updates, particularly with ICD-10-CM/OCS and AMA CPT coding guidelines, to identify and develop methods to enhance research strategies, processes, policies, and procedures within the WTC Health Program in accordance with the functions and objectives of the Research and Evaluation Branch and Quality and Evaluation Team.

• Collaborate with clinicians, medical administrators, federal staff, contract personnel, and occupational health subject matter experts to support medical management, claims review, audit activities, and prior authorization recommendations.

• Link claims quality findings to overarching quality assurance, utilization review, and program evaluation goals, identifying issues that may impact Program operations, reporting, or policy implementation.

⛳️ Requirements

• A bachelor’s or master’s degree in a health-related field (HIM, MPH, MHA, RN, PA, or another health profession) is preferred.

• At least 5 years of experience working with health insurance payer claims data in a health plan or managed care environment, with a focus on healthcare quality, medical coding, and claims auditing.

• Proven expertise in CPT, HCPCS, and ICD billing codes, including knowledge of authorization requirements, documentation, DRG, and healthcare claims data analysis.

• Certifications such as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Certified Coding Specialist (CCS) are desirable.

• Proficient in Microsoft Office Suite, including Excel, Outlook, and SharePoint.

🏝️ Benefits

• Paid leave.

• Options for employer-sponsored group medical, dental, vision, short-term and long-term disability, life insurance, AD&D coverage, legal services, identity theft, and accident insurance.

• Flexible spending account and health savings account options provide pre-tax savings for qualified medical, dental, and vision expenses.

• The company-sponsored 401(k) retirement plan includes an employer contribution match that is immediately vested.

• We prioritize the professional development of our employees through professional courses, certifications, and tuition reimbursement programs.