Remote Clinical Claims Investigator & Auditor

HCSC; Tulsa (OK); Remote; USD 63,000 - 114,000; Full time

Job summary

Health Care Service Corporation (HCSC) is seeking a claims audit specialist to review clinical, billing and coding activities for pre- and post-payment claims. This role involves researching supporting documentation and coordinating with medical directors, customer service, network management, and pricing teams.

Applicants should have a bachelor’s degree, coding certification or plan to obtain within 24 months, and at least three years of experience in claims processing and auditing.

Qualifications

• Bachelor’s degree; one year of business experience, law enforcement experience, or regulatory agency experience may substitute for each year of college.
• Certified Coding Certification, or acquire within 24 months of hire
• 3 years of experience in claims processing operations and reporting systems, including 2 years of experience in auditing or developing computer system reports.
• Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation.
• Awareness of claims processes and claims processing systems.
• PC proficiency to include Microsoft Word and Excel and health insurance databases.
• Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings.
• Organizational skills and prioritization skills

Responsibilities

• Audit clinical, billing, coding and lowest cost setting reviews for services pre and post payment.
• Conduct research and prepare documentation of findings; consult with special investigations and other areas as needed.
• Coordinate with departments such as medical director special investigations, customer service, pass, network management, pricing and database.

Skills

Auditing

Communication

Organizational skills

Research

Education

Bachelor’s degree

Certified Coding Certification

Tools

Microsoft Word

Microsoft Excel

Health insurance databases

Job description

Health Care Service Corporation (HCSC) is seeking a claims audit specialist to review clinical, billing and coding activities for pre- and post-payment claims. This role involves researching supporting documentation and coordinating with medical directors, customer service, network management, and pricing teams.

Applicants should have a bachelor’s degree, coding certification or plan to obtain within 24 months, and at least three years of experience in claims processing and auditing.