Lead Auditor, Medical Claims

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Requirements:

• 10+ years of relative Medical coding and claims auditing experience
• Experienced in analyzing payment information against Medicare and payer billing guidelines to assess the accuracy and appropriateness of payments
• Deliver timely high-quality work within a fast pace and ambiguous environment
• Strong attention to detail; investigative and deductive reasoning skills are a must
• Ability to navigate an autonomous work environment and manage competing priorities
• Must be able to make decisions and conclusions when working with limited information using reference materials and strong problem-solving skills.
• Proficiency in using productivity tools (e.g., Excel, Word, Gmail, Google Sheets, Slack, etc.); intermediate spreadsheet skills level, to include: ability to manipulate a spreadsheet, use formulas, work with pivot tables, run macros within existing spreadsheets; some training provided.
• Certifications in medical coding and billing (CCS, CPC, RHIA, RHIT etc)

Responsibilities:

• Develop new auditing concepts by utilizing experience and knowledge of the claims payment cycle, contracts, policies and guidelines
• Conduct comprehensive reviews of post pay claims using any and all available resources. Including but not limited to...claims data and client adjudication systems, payment guidelines and compliance with regulatory requirements, contract, pricing systems, medical records, authorizations, etc.
• Serve as a resource and expert in claims billing and payment for the data teams and other departments
• Develop and refine reimbursement policies and procedures in collaboration with the team
• Proactively keep up to date with the latest healthcare billing guidelines and regulations
• Achieve the expected level of accuracy and quality set by the client for the auditing concept, for valid claim identification and documentation
• Identifies potential claims outside of the concept where additional recoveries may be available. Suggest and develop high-quality, high-value concepts and or process improvement, tools, etc.
• Additional responsibilities as assigned or needed to support the business.