Auditor Claims BCI

Highmark Health; Pennsylvania; On-site; USD 30,000 - 45,000; Full time

Job summary

Highmark Health in Pennsylvania is seeking a Claims Auditor to review medical, dental, vision, FSA and HRA claims for accuracy and compliance. You will examine coding, benefit rules and documentation, and document audit results to support monthly reporting.

The role requires detail orientation, strong problem-solving and communication skills, and the ability to work independently or within a claims team in a fast-paced environment.

Qualifications

• 5 years prior medical, dental, vision, FSA and HRA claims processing experience.
• Knowledge of CPT, HCPCS, ICD9 and ICD10.
• Strong attention to detail with organizational skills.
• Excellent verbal and written communication.
• Proficient PC navigation; basic MS Excel and Word.
• Ability to work independently or in a team.
• Ability to reference resources to resolve claim audits.

Responsibilities

• Audit claims and monitor audits for timely turnaround.
• Prepare and maintain audit results for monthly reporting.
• Provide coaching and guidance to claims staff.
• Support system upgrade testing and special audits.
• Handle refunds, voids, and stop payments.
• Liaise with clients and management regarding audits and findings.

Skills

CPT/HCPCS/ICD10

Attention to detail

Problem solving

Communication skills

MS Excel

MS Word

Teamwork

Education

HS/GED

Associate degree (preferred)

Tools

Excel

Word

Claims processing system

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.ADAE1. 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 staffE6. 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 organizationE11. Manage the refund, void and stop payment processE12. 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 assignedEducation/Experience/Skills RequirementsRequired Education:HS/GED:Required Experience:5 years prior medical dental, vision, FSA and HRA claims processing experience. Preferred: Associate DegreeRequired Knowledge/Skills:1. Comprehensive understanding of CPT, HCPCS, ICD9 and ICD10 medical coding2. Strong attention to details along with organizational skills3. Excellent problem solving with the ability to work in a fast paced production environment4. Excellent communication skills both verbal and written5. PC navigation skills for Professional work environment6. Basic MS Excel7. Basic MS Word8. Ability to use judgement to make sound decisions referencing all available resources9. Ability to work independently and also as part of a teamRequired Licenses/Certifications:Problem SolvingAbility 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 ResponsibilitiesDoes this Position have Supervisory Responsibility? NoNumber of Emps Supervised:Titles of Employees Supervised:Financial/Budgetary Responsibilities:Other Job Specifications:External Contacts:Working Conditions/Physical Demands:Pay Range Minimum:$21.96Pay Range Maximum:$32.95Base 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.We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.For accommodation requests, please contact HR Services Online at [e-mail] Consumer Privacy Act Employees, Contractors, and Applicants Notice