High-Dollar Claims Auditor & DRG Specialist

MagnaCare; Chapel Hill (NC); On-site; USD 70,000 - 100,000; Full time

Job summary

Brighton Health Plan Solutions is seeking a High Dollar Specialist to review high-dollar claims for accurate billing, pricing, and adjudication. This role supports the Quality Department and interfaces with multiple stakeholders.

The ideal candidate has significant facility-based billing experience, DRG expertise, and 3–5+ years in coding and claims examination, with strong communication and organizational skills.

Qualifications

• Significant experience in facility-based billing.
• Experience with physician/ancillary billings.
• Expertise in DRG Groupers.
• 3–5+ years coding and claims examination experience.
• Knowledge of Drug Reimbursement methods including AWP and J-codes.
• Familiarity with hospital billing systems and healthcare terminology.
• Excellent follow-up, organization and time management.
• Strong communication skills (written and oral).

Responsibilities

• Review high-dollar claims to ensure pricing and billing accuracy, including implant, supply, observation, and drug/procedure units.
• Review DRG for accuracy compared to billed procedures, diagnoses, and patient age.
• Develop reporting mechanisms to track high-dollar claims information.
• Collaborate with CMO, Legal, and other departments as needed.
• Coordinate efforts with external vendors as required.

Skills

DRG Groupers

Facility billing

Physician/ancillary billing

Coding & claims review

Drug reimbursement (AWP, J-codes)

Hospital billing systems

Communication skills

Follow-up & time management

Independent work

Job description

Brighton Health Plan Solutions is seeking a High Dollar Specialist to review high-dollar claims for accurate billing, pricing, and adjudication. This role supports the Quality Department and interfaces with multiple stakeholders.

The ideal candidate has significant facility-based billing experience, DRG expertise, and 3–5+ years in coding and claims examination, with strong communication and organizational skills.