Senior Claims Auditor - Hybrid (Healthcare Payer)

Covet Health Inc.; New York (NY); Híbrido; USD 39 000 - 45 000; Tempo integral

Resumo da oferta

Covet Health Inc. is hiring a claims processor/examiner with 4+ years of healthcare payer experience. The role focuses on day-to-day claims processing, adjudication, and research to verify coverage and medical necessity under policy guidelines.

You will work in a hybrid setup with three days in Midtown Manhattan, collaborating with claims managers and cross-functional teams. Strong communication, COBRA/HIPAA knowledge, and proficiency in UB-04/CMS-1500 forms are essential.

Qualificações

• 4+ years related work experience in healthcare payer claims processing/adjudication.
• Knowledge of CPT, HCPCS, RVU, and ICD-10 coding.
• Experience handling COBRA, HIPAA and coordination of benefits.
• Proven judgment, decision-making and analytical skills.
• Excellent written and verbal communication, including conflict handling.

Responsabilidades

• Process claims day-to-day based on CPT, ICD-10, POS codes, provider types (Professional, Institutional, Mental Health, Vision and Dental).
• Perform claims processing and adjudication and research supporting audits.
• Review medical records, itemized bills, authorizations, and member enrollment as needed.
• Verify coverage and medical necessity per policy guidelines; apply clinical edit logic.
• Use systems to track complaints and resolutions; monitor daily output for accuracy.
• Collaborate with claims managers, adjusters, and third-party administrators; identify system configuration discrepancies.
• Manage assignments and projects, participate in daily huddles and status updates to align on priorities and updates.
• Read UB-04 and CMS-1500 forms to distinguish in-network vs out-of-network coverage.

Conhecimentos

TPA claims examiner

CPT/HCPCS/ICD-10 knowledge

COBRA/HIPAA knowledge

cost-sharing understanding

strong communication

Ferramentas

VBASoftware Database

Descrição da oferta de emprego

Covet Health Inc. is hiring a claims processor/examiner with 4+ years of healthcare payer experience. The role focuses on day-to-day claims processing, adjudication, and research to verify coverage and medical necessity under policy guidelines.

You will work in a hybrid setup with three days in Midtown Manhattan, collaborating with claims managers and cross-functional teams. Strong communication, COBRA/HIPAA knowledge, and proficiency in UB-04/CMS-1500 forms are essential.