Clinical Coding Investigator & Claims Auditor

HCSC Group; Northern (KY); Hybrid; USD 63,000 - 114,000; Full time

Job summary

HCSC is seeking an experienced health care claims auditor to review clinical, billing, and coding for pre- and post-payment validations. You will research findings, document results, and consult with the affordability of care team as needed.

You will coordinate with medical directors, customer service, network management, pricing and data teams to ensure accurate, compliant claim processing across departments.

Qualifications

• Bachelor's degree required; experience substituting for college is allowed.
• Certified Coding Certification or obtain within 24 months of hire.
• 3 years of claims processing operations and reporting systems experience.
• 2 years of auditing or developing computer system reports experience.
• Knowledge of URAC/NCQA standards and health insurance legislation.

Responsibilities

• Audit clinical, billing, coding and lowest cost setting reviews for services pre and post payment.
• Research and document findings; consult with special investigations and affordability of care teams as needed.
• Coordinate with medical director special investigations, customer service, pricing and data teams.
• Collaborate with pricing, network management, marketing, case management, legal and other departments on cases.

Education

Bachelor's degree

Certified Coding Certification

Tools

Microsoft Word

Excel

Health insurance databases

Job description

HCSC is seeking an experienced health care claims auditor to review clinical, billing, and coding for pre- and post-payment validations. You will research findings, document results, and consult with the affordability of care team as needed.

You will coordinate with medical directors, customer service, network management, pricing and data teams to ensure accurate, compliant claim processing across departments.