High-Value Claims Auditor

brightonhealthplansolutions; Chapel Hill (NC); On-site; USD 75,000 - 105,000; Full time

Job summary

Brighton Health Plan Solutions is seeking a High Dollar Specialist to review high dollar claims for accuracy in billing, pricing and adjudication. The role supports the Quality Department and collaborates with internal and external stakeholders to ensure proper reimbursement and compliance.

The ideal candidate has 3–5 years of coding and claims examination experience, strong DRG knowledge, and familiarity with physician and ancillary billing, plus excellent written and verbal communication to

Qualifications

• 3–5 years of coding and claims examination experience.
• Experience with facility-based billing.
• Experience with physician/ancillary billings.
• Expertise in DRG Groupers.
• Ability to calculate J code reimbursements.
• Familiarity with hospital billing systems and healthcare terminology.
• Impeccable follow up, organization, and time management skills.
• Strong written and oral communication.

Responsibilities

• Review high dollar claims to ensure pricing and billing accuracy, including implant and supply charges, observation room charges, and units billed for drugs and procedures.
• Review DRG for accuracy as compared to billed procedures, diagnosis/condition, age, etc.
• Develop reporting mechanisms to track claims information related to high dollar claims.
• Collaborate with CMO, Legal and other departments as needed.
• Coordinate efforts with external vendors as required.

Skills

High dollar claims review

DRG expertise

Facility-based billing

Physician/ancillary billing

J-code reimbursements

Healthcare terminology

Time management

Communication skills

Independent working

Tools

Hospital billing systems

Job description

Brighton Health Plan Solutions is seeking a High Dollar Specialist to review high dollar claims for accuracy in billing, pricing and adjudication. The role supports the Quality Department and collaborates with internal and external stakeholders to ensure proper reimbursement and compliance.

The ideal candidate has 3–5 years of coding and claims examination experience, strong DRG knowledge, and familiarity with physician and ancillary billing, plus excellent written and verbal communication to