Medical Claims Auditor II - Remote

HMS - Nevada (30+ days ago)3.2


We are seeking a talented individual for a Medical Claims Auditor II who performs research analytics to support our recovery audit line of business. Assists in the development and implementation of new data mining and audit/review methodologies for identifying healthcare overpayments and underpayments to providers, and the detection of healthcare fraud, waste, and abuse.

Essential Responsibilities:
Participates in the review of health insurance claims and member eligibility information to uncover claims overpayment trends associated with non-compliance or misapplication of contract terms and rates, payment policies, medical policies, billing guidelines, and applicable regulatory requirements. Applies knowledge of provider billing and patient accounting practices to research of client policy and data to reveal new overpayment recovery opportunities. Works with data miners, clinical staff, and stakeholders to identify new overpayment issues for each client.
Tracks, and follows-up on results and recoveries
Contributes new ideas for improving existing audit processes and audit queries. Works cohesively with the audit team.
Develops, maintains, and ensures adherence to multiple project schedules

Non-Essential Responsibilities:
Performs other functions as assigned

Qualifications : Knowledge, Skills and Abilities:
Strong conceptual and analytical skills
Strong Project Management skills
Ability to develop, organize, and maintain project plans and agendas
Ability to effectively interface with clients
Working knowledge of Microsoft Suite of products (Excel, Word, Access)
Understanding or medical terminology and anatomy.
Understanding of Medicaid required, Medicare and commercial experience a plus.
In depth knowledge of coding principals including but not limited to NCCI Edits, CPT, HCPCS and ICD-9 codes and modifiers; and/or MSDRG, Revenue codes, and APCs.
In depth knowledge of UB04 and medical (1500) claim formats and requirements.

Work Conditions and Physical Demands:
Primarily sedentary work in a general office environment
Ability to communicate and exchange information
Ability to comprehend and interpret documents and data
Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)
Requires manual dexterity to use computer, telephone and peripherals
May be required to work extended hours for special business needs
May be required to travel at least 10% of time based on business needs

Minimum Education:
High school diploma or GED required;
Bachelor’s degree preferred

Minimum Related Work Experience:
4+ years of healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, and/or revenue cycle improvement required.
Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-9-CM codes, HCPCS codes, CPT codes, DRGs, physician billing, etc..
Experience in healthcare auditing, reviewing and validating the accuracy of claims data and accuracy of claims payment preferred.
Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data, Recovery audit experience a plus preferred
Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.
Job Posting : Aug 8, 2018, 3:45:37 PM
Work Locations : USA-Nevada-NV-Remote