Claims Auditor

Job Title: Medical Claims Auditor I

Contract Duration: 6+ Months (Temp - Hire)

Location: Remote

Job 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

• Performs other functions as assigned.