Auditor Claims BCI

Highmark; United States; On-site; USD 30,000 - 45,000; Full time

Job summary

Highmark Inc. is seeking a claims auditing specialist to ensure accurate processing of medical/dental/vision/HRA/FSA claims. You will monitor audit workflows, coach junior staff, and provide expert guidance on complex claim situations across multiple plans.

Ideal candidates have extensive CPT/HCPCS/ICD9/ICD10 knowledge, strong problem solving and communication skills, and the ability to work both independently and within a team in a fast-paced environment.

Qualifications

• 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

Responsibilities

• Ensure all claims are handled according to internal procedures and review plan wording for each employer group
• Monitor workflow of audits to ensure timely turnaround and meet guidelines
• Maintain workload in line with quality and production standards for auditing
• Record results in audit tool and report monthly; partner with supervisor to run training sessions
• Conduct one-on-one coaching with the claims team, including trainees
• Provide recommendations for dollar authorization based on audit stats
• Assist with specialized audits for SOC, carrier, vendor and employer audits
• Maintain knowledge of benefits, regulations and system upgrades
• Review complex claim situations to render sound decisions using all resources
• Liaise with clients, management, and peers with clear communication
• Manage refund, void and stop payment processes
• Guide claims team on all aspects of processing and system upgrades
• Handle other duties as assigned

Skills

CPT/HCPCS/ICD9/ICD10 coding

Attention to detail

Problem solving

Communication skills

PC navigation

MS Excel

MS Word

Decision making

Teamwork

Independent work

Education

HS/GED

Associate Degree (preferred)

Job description

Job Description

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

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

• 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

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

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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