Auditor Claims BCI

Highmark Health; Providence (RI); On-site; USD 30,000 - 45,000; Full time

Job summary

Highmark Inc. is seeking a claims auditor to ensure audits are performed in line with internal procedures and contract terms. The role involves reviewing plan wording, monitoring audit workflows, and coaching the claims team to improve accuracy and compliance.

The candidate will maintain knowledge of benefits, state and federal guidelines, and coordinate with supervisors for training and process improvements. Strong CPT/HCPCS/ICD coding knowledge and attention to detail are essential.

Qualifications

• Comprehensive understanding of CPT, HCPCS, ICD9 and ICD10 coding.
• Strong attention to detail and organizational skills.
• Ability to work in a fast-paced production environment.
• Excellent communication skills both verbal and written.
• Proficient in MS Excel and MS Word.
• Ability to use judgment to make sound decisions referencing all available resources.
• Ability to work independently and also as part of a team.

Responsibilities

• Handle claims audits and review plan wording.
• Coach and train claims staff; conduct training sessions.
• Record audit results and assist with system upgrades.
• Support SOC, carrier, vendor, and employer audits.
• Liaise with clients and management; manage refunds and stop payments.
• Provide guidance to the claims team on all aspects of claims processing.
• Assist with system upgrade testing.

Skills

CPT/HCPCS

ICD9/ICD10

Attention to detail

Problem solving

Communication skills

Excel basics

Word basics

Independent work

Teamwork

Education

HS/GED

Associate Degree (preferred)

Tools

MS Excel

MS Word

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.

ADA

• 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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