Senior Medical Claims Investigator

Claritev; United States; On-site; Full time

Job summary

A leading company is seeking a Senior Medical Claims Investigator to join their innovative team in healthcare. This role involves reviewing medical claims for accuracy and mentoring junior staff while contributing to cost-saving initiatives. Ideal candidates will possess strong coding expertise and experience with data mining techniques.

Benefits

Medical coverage

401(k) company match

Paid Parental Leave

Generous Paid Time Off

Tuition reimbursement

Qualifications

• Minimum high school diploma with 4 years in medical claims investigation.
• Expert in medical coding and reimbursement methodologies.
• Experience with coding rules and guidelines, federal/state regulations.

Responsibilities

• Review medical claims against contracts to ensure accurate payments.
• Use analytics and data mining to identify savings opportunities.
• Mentor junior team members and assist department leadership.

Skills

Medical terminology

Data mining

Analytical skills

Coding expertise

Education

Bachelors' degree in a relevant field

Medical billing and coding certification

Tools

Microsoft Excel

Job description

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At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our purpose is simple - we strive to bend the cost curve in healthcare for all. Our dedication to service excellence extends to all our stakeholders - internal and external - driving us to consistently exceed expectations. We are intentionally bold, we foster innovation, we nurture accountability, we champion diversity, and empower each other to illuminate our collective potential.

Be part of our amazing transformational journey as we optimize the opportunity towards becoming a leading technology, data, and innovation voice in healthcare. Onward and Upward!!!

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Job Summary

This role reviews medical paid claims against provider contracts and policies to ensure medical payments have been processed accurately. The incumbent will employ data mining and coordination of benefit techniques to analyze and audit hospital and physician claims to identify errant claim payments. The incumbent will assist department leadership in managing productivity and achieving quality and revenue goals as well as mentoring more junior department team members when appropriate.

Job Roles And Responsibilities

• Achieve measured production, quality, and growth results.
• Utilize analytics, data mining and coordination of benefit techniques to client paid claims data, develop creative and innovative algorithms and queries that facilitate identification of new savings opportunities.
• Evaluate medical claims for coding and pricing errors using accurate HCPCS, ICD-10, and CPT codes.
• Research coding rules and guidelines in support of internal and external pre-pay edits.
• Lookup and review medical claims in payer system to determine methods of payment and validate savings identified.
• Provide coding expertise on reimbursement policy, provider contractor investigations, and prepay editing topics.
• Represent team in payment policy discussions and when necessary, and document new policies or modifications to existing policies.
• Act as a subject matter expert using internal and external tools in order to complete audits and provide guidance to team members.
• Aid in the training and peer review of others in the department for data mining / coordination of benefits and auditing best practices.
• Act as a mentor by answering questions regarding contracts, policies, and medical coding.
• Assist in provider collection efforts and appeal resolution as needed.
• Prepare comprehensive overpayment white papers and present to client
• Utilize official coding guidelines and resources as required, including CMS directives and bulletins.
• Collaborate, coordinate, and communicate across disciplines and departments.
• Ensure compliance with HIPAA regulations and requirements.
• Demonstrate Company's Core Competencies and values held within.
• Please note due to the exposure of PHI sensitive data -- this role is considered to be a High-Risk Role.
• The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.
  
  

Job Scope

This role keeps the needs of external and internal customers as a priority when making decisions and taking action. The incumbent will work under limited supervision to uncover actionable claims which facilitate savings for customers. The role may task the incumbent with regular interaction amongst all levels of customers and internal staff in the organization.

,

JOB REQUIREMENTS (Education, Experience, And Training)

• Minimum high school diploma or GED along with four (4) years of direct experience in medical claims investigation or data mining / coordination of benefits auditing. Attainment of relevant medical billing and coding certification along with a bachelors' degree in a relevant field are both highly preferred.
• Advanced knowledge of coding type edits and medical claim reimbursement structures and methodologies
• Advanced proficiency with medical terminology, medical procedures, medical conditions, and illness and treatment practices
• Expertise in COB NAIC Guidelines
• Extensive experience in applying principles of coding guidelines; federal/state regulations and policies pertaining to coding and billing
• Subject matter expert in reviewing and interpreting medium to complex medical contracts
• Experience providing guidance to other employees on coding regulations and reimbursement structures
• Extensive knowledge in researching state and federal healthcare guidelines, i.e. Medicare and State Medicaid Programs
• Familiarity with automated medical claims payment systems and/or working knowledge of payer systems (i.e. Facets, QNXT, etc.)
• Advanced computer skills and proficiency with Microsoft Excel
• Must be able to prioritize, coordinate, multitask, think outside the box, and be energetic
• Must be able to work independently while maintaining close attention to detail
• Required licensures, professional certifications, and/or Board certifications as applicable
• Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone
  
  

The salary range for this position is $31.25-$33.65 per hour. Specific offers take into account a candidate’s education, experience and skills, as well as the candidate’s work location and internal equity. This position is also eligible for health insurance, 401k and bonus opportunity.

Benefits

We realize that our employees are instrumental to our success, and we reward them accordingly with very competitive compensation and benefits packages, an incentive bonus program, as well as recognition and awards programs. Our work environment is friendly and supportive, and we offer flexible schedules whenever possible, as well as a wide range of live and web-based professional development and educational programs to prepare you for advancement opportunities.

Your Benefits Will Include

• Medical (PPO & HDHP), dental and vision coverage
• Pre-tax Savings Account (FSA & HSA)
• Life & Disability Insurance
• Paid Parental Leave
• 401(k) company match
• Employee Stock Purchase Plan
• Generous Paid Time Off - accrued based on years of service
• WA Candidates: the accrual rate is 4.61 hours every other week for the first two years of tenure before increasing with additional years of service
• 10 paid company holidays
• Tuition reimbursement
• Employee Assistance Program
• Sick time benefits - for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year, unless the laws of the state in which the employee is located provide for more generous sick time benefits
  

As an Equal Opportunity Employer, the Company will provide equal consideration to all employees and job candidates without regard to sex, age, race, marital status, sexual orientation, religion, national origin, citizenship status, physical or mental disability, political affiliation, service in the Armed Forces of the United States, or any other characteristic protected by federal, state, or local law.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Finance and Sales

• Industries

  Hospitals and Health Care

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