Auditor Claims BCI

highmarkhealth; Pennsylvania; Hybrid; USD 30,000 - 45,000; Full time

Job summary

Highmark Health seeks a senior claims auditor to ensure accurate processing of medical, dental, and vision benefits. You will review plans, monitor audits, and coach staff while maintaining high standards of accuracy and efficiency.

The role requires extensive coding knowledge, 5 years of experience, and strong communication skills. Competitive pay and benefits accompany a structured environment with opportunities for system upgrades testing.

Qualifications

• Strong knowledge of CPT, HCPCS, ICD9 and ICD10 coding.
• 5 years medical/dental/vision, FSA and HRA claims processing experience.
• Attention to detail and organizational skills.
• Excellent verbal and written communication skills.
• Proficiency with MS Excel and MS Word.
• Ability to use judgement to make sound decisions with available resources.
• Ability to work independently and as part of a team.

Responsibilities

• Handle claims per internal procedures and review plan documents for each employer group.
• Monitor audits to ensure timely turnaround and identify performance issues.
• Maintain workload to meet quality and production standards for the auditing team.
• Record results in the audit tool and assist supervisor with training sessions.
• Conduct one-on-one coaching with trainee staff.
• Provide recommendations for dollar authorization based on audit stats.
• Assist with SOC, carrier, vendor and employer audits as needed.
• Maintain knowledge of benefits, state/federal regulations and system upgrades.
• Provide expertise to claims team on complex claims to render sound decisions.
• Liaise with clients and internal teams using clear written or verbal communication.
• Manage refund, void and stop payment processes.
• Guide the claims team on all aspects of claims processing.
• Assist in system upgrade testing.
• Handle other duties as assigned.

Skills

CPT/HCPCS/ICD9/ICD10

Attention to detail

Problem solving

Communication skills

MS Excel

MS Word

Judgment

Independent & team work

Time management

Education

HS/GED

Associate degree (preferred)

Tools

MS Word

Job description

Company

Highmark Inc. Job Description :

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

Job Duties

• 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.
• E14. 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:
  • Comprehensive understanding of CPT, HCPCS, ICD9 and ICD10 medical coding
  • Strong attention to details along with organizational skills
  • Excellent problem solving with the ability to work in a fast paced production environment
  • Excellent communication skills both verbal and written
  • PC navigation skills for Professional work environment
  • Basic MS Excel
  • Basic MS Word
  • Ability to use judgement to make sound decisions referencing all available resources
  • Ability to work independently and also as part of a team
• Required Licenses/Certifications: Problem Solving
• Additional Responsibilities: 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

• 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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