Auditor Claims BCI

Highmark Health; United States; Hybrid; USD 30,000 - 45,000; Full time

Job summary

Highmark Health in the United States (KY region) seeks a Claims Audit Specialist with 5 years of medical claims processing experience in dental, vision, FSA and HRA. You will ensure claims follow procedures, monitor audits, record results, and coach staff to maintain accuracy and efficiency.

You will support supervision, recommend dollar authorizations based on audit stats, conduct specialized audits, and test system upgrades.

Qualifications

• Comprehensive understanding of CPT, HCPCS, ICD9 and ICD10 medical coding.
• Strong attention to detail and organizational skills.
• Ability to problem solve and work in a fast-paced environment.
• Excellent written and verbal communication skills.
• Basic MS Excel and Word proficiency.
• Use good judgment referencing all resources to decide on next steps.
• Ability to work independently and as part of a team.

Responsibilities

• Ensure all claims are handled per internal procedures and review plan wording.
• Monitor audits to meet turnaround time and identify performance issues.
• Maintain workload to meet quality and production standards.
• Record results in the audit tool for monthly reporting.
• Coach staff one-on-one and provide guidance on audits.
• Make recommendations for dollar authorization based on audit stats.
• Assist with specialized SOC, carrier, vendor and employer audits.
• Maintain knowledge of benefits, regulations and system upgrades.
• Provide expertise to claims team for complex claim issues.
• Liaise with clients and management using strong communication.
• Manage refund, void and stop payment processes.
• Assist with system upgrade testing and other duties as assigned.

Skills

CPT coding

HCPCS coding

ICD9/ICD10

Detail orientation

Problem solving

Communication skills

MS Excel

MS Word

Independent & team work

Education

HS/GED

Associate Degree

Job description

Company : Highmark Inc. Job Description : Duties

Note: The following is not intended to be an exhaustive list of all duties required of this position.

• E1. Ensure all claims are handled according to all internal operating and administrative procedures along with reviewing plan wording for each individual employer group, which should include the plan document, amendments, matrices and benefit summary.
• E2. Monitor workflow of audits to ensure timely turnaround time. Identify the performance guarantee group’s audits to meet the strict guidelines for turnaround time.
• E3. Maintain workload in accordance with the quality and production standards defined for the auditing team.
• E4. Record results in the audit tool for monthly reporting. Partner with the supervisor to create and conduct training sessions for issues identified by the management team.
• E5. Conduct one on one coaching with the claims team especially the trainee staff
• E6. Provide recommendation for dollar authorization for claims team members based on audit stats and interaction with individual claim team members.
• E7. Assist supervisor with specialized audits for the SOC process, carrier, vendor and employer audits as necessary.
• E8. Maintain detailed knowledge of benefits, state regulations, federal guidelines and system upgrades.
• E9. Review and provide expertise to the claims team with complex claim situation/issues by using all resources to render a sound decision.
• E10. Utilize excellent written or verbal communication skills to liaise with clients, management, peers and other areas within the organization
• E11. Manage the refund, void and stop payment process
• E12. Provide guidance to the claims team with questions on all aspects of claims processing.
• E13. Assist with system upgrade testing.
• N14. Handle other duties as assigned

Education/Experience/Skills Requirements

Required Education: HS/GED:

Required Experience: 5 years prior medical dental, vision, FSA and HRA claims processing experience.

Preferred: Associate Degree

Required Knowledge/Skills:

• 1. Comprehensive understanding of CPT, HCPCS, ICD9 and ICD10 medical coding
• 2. Strong attention to details along with organizational skills
• 3. Excellent problem solving with the ability to work in a fast paced production environment
• 4. Excellent communication skills both verbal and written
• 5. PC navigation skills for Professional work environment
• 6. Basic MS Excel
• 7. Basic MS Word
• 8. Ability to use judgement to make sound decisions referencing all available resources
• 9. Ability to work independently and also as part of a team

Required Licenses/Certifications: Problem Solving Ability to research and seek assistance through all available resources, to ensure resolution on claim audits. Must be able to multi-task and follow up at appropriate intervals. Raise concerns to the management team on situations and/or issues in a timely manner.

Managerial/Supervisory Responsibilities

Does this Position have Supervisory Responsibility? No

Number of Emps Supervised:

Titles of Employees Supervised:

Financial/Budgetary Responsibilities:

Other Job Specifications:

External Contacts:

Working Conditions/Physical Demands

Pay Range Minimum: $21.96 Pay Range Maximum: $32.95 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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For accommodation requests, please contact HR Services Online at [e-mail] California Consumer Privacy Act Employees, Contractors, and Applicants Notice Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network.

Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.