Remote High-Dollar Claims Auditor

Brighton Health Plan Solutions; Chapel Hill (NC); On-site; USD 65,000 - 95,000; 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 remote role involves interacting with many internal and external stakeholders to help ensure quality and compliance in the claims process.

You will review pricing, pricing implants and supply charges, DRG accuracy, and related charges; develop reporting to track high dollar claims; and collaborate with the CMO, Legal and external vendors as needed.

Qualifications

• Significant experience in facility-based billing.
• Experience with physician/ancillary billings.
• Expertise in DRG Groupers.
• 3–5+ years of coding and claims examination experience.
• Knowledge of Drug Reimbursement methodologies including AWP; ability to calculate J codes.
• Familiarity with hospital billing systems and healthcare terminology.
• Impeccable follow up, organization, and time management.
• Ability to work independently with management and external stakeholders.
• Strong written and oral communication abilities.

Responsibilities

• Review high dollar claims to ensure pricing and billing accuracy (implants, supply charges, observation room charges, unit charges).
• Review DRG for accuracy against billed procedures, diagnosis, age, etc.
• Develop reporting to track high dollar claims information.
• Collaborate with CMO, Legal and other departments as needed.
• Coordinate efforts with external vendors as required.

Skills

Facility billing

Physician/ancillary billing

DRG groupers

Coding & claims exam

Drug reimbursement (AWP & J codes)

Hospital billing systems

Follow-up & organization

Stakeholder collaboration

Communication skills

Learning mindset

Job description

Brighton Health Plan Solutions is seeking a High Dollar Specialist to review high dollar claims for accurate billing, pricing and adjudication. This remote role involves interacting with many internal and external stakeholders to help ensure quality and compliance in the claims process.

You will review pricing, pricing implants and supply charges, DRG accuracy, and related charges; develop reporting to track high dollar claims; and collaborate with the CMO, Legal and external vendors as needed.