Remote RN Hospital Claims Auditor

Page Mechanical Group, Inc.

Portland (OR)

On-site

USD 79,000 - 99,000

Full time

14 days+

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Benefits offered by this job

Medical, Dental, Vision, Pharmacy, Lif

Disability

401K Matching

FSA

Employee Assistance Program

PTO and Company Paid Holidays

Job summary

Moda Health in Oregon seeks a Hospital Billing Coordinator/Auditor to provide clinical and technical analysis for interpretation of hospital inpatient claims and related inputs. This full-time, work-from-home role offers a competitive pay range and comprehensive benefits.

Responsibilities include identifying billing irregularities, adjudicating claims when appropriate, and reviewing DRG validation and other reviews.

Qualifications

3 – 5 years’ experience as a hospital billing coordinator and/or auditor.
Certified Professional Coder preferred.
2 years’ health insurance industry experience, with prior experience in auditing hospital claims preferred.
RN licensure required, BSN desired.
Prior experience in review of medical records.
Proficiency with Microsoft Office applications and internet research.
Strong organizational, analytical and problem-solving skills required.
Excellent oral and written communications.
Ability to work well under pressure in a complex and rapidly changing environment.
Maintain confidentiality and project a professional business appearance.

Responsibilities

Identify billing irregularities on hospital bills with appropriate level of review.
Determine need for claims adjudication with no further review or request records for further review.
Perform pre and post pay medical claim reviews utilizing itemized hospital bills and other documentation as needed.
Assist with DRG validation, appropriate level of care, inpatient readmission, and related opportunities identified by the payment integrity analytical team.
Document review findings for processing staff and prepare written communication of findings for hospital representatives.
Provide guidance on proper coding and edits to support accurate claim payments.
Collaborate with Moda areas to ensure appropriate and cost-efficient claim processing decisions.
Review provider and member complaints to identify trends and suggest improvements.
Provide consultation in review of appealed claims requiring interpretation of clinical and pricing documentation.
Monitor contracted vendors that provide services to control claims expenses through negotiation and audits.
Educate employees and providers on CPT, ICD, HCPCS usage.
Performs other related duties and projects.