Medical Claims Audit & Training Specialist

Highmark Health; Atlanta (GA); Vor Ort; USD 46.000 - 69.000; Vollzeit

Zusammenfassung

Highmark Inc. is seeking an experienced claims auditor to ensure compliance with internal procedures and accurate processing of medical, dental, vision, FSA and HRA claims.

The role focuses on audit workflow, coaching the claims team, and performing specialized audits for SOC, carrier, vendor and employer programs, while staying current on benefits, regulations and system upgrades. Strong communication and detail orientation are essential.

Qualifikationen

• 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

Aufgaben

• E1. Ensure all claims are handled according to internal procedures and review plan wording.
• E2. Monitor audits to meet turnaround time and quality standards.
• E3. Maintain workload in accordance with production standards.
• E4. Record results in the audit tool for monthly reporting and train staff as needed.
• E5. Conduct one on one coaching with the claims team.
• E6. Provide recommendations for dollar authorization based on audit stats.
• E7. Assist with specialized SOC, carrier, vendor and employer audits.
• E8. Maintain knowledge of benefits, regulations, and system upgrades.
• E9. Review complex claims and render sound decisions.
• E10. Liaise with clients, management, peers and other areas.
• E11. Manage refund, void and stop payment processes.
• E12. Guide claims staff on all aspects of processing.
• E13. Assist with system upgrade testing.
• N14. Handle other duties as assigned

Kenntnisse

CPT/HCPCS/ICD9/ICD10 knowledge

Attention to detail

Problem solving

Communication skills

PC navigation

MS Excel

MS Word

Judgement

Teamwork

Ausbildung

HS/GED

Associate degree preferred

Jobbeschreibung

Highmark Inc. is seeking an experienced claims auditor to ensure compliance with internal procedures and accurate processing of medical, dental, vision, FSA and HRA claims.

The role focuses on audit workflow, coaching the claims team, and performing specialized audits for SOC, carrier, vendor and employer programs, while staying current on benefits, regulations and system upgrades. Strong communication and detail orientation are essential.