Sr. Medical Claims Investigator

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:

1. Achieve measured production, quality, and growth results.
2. 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.
3. Evaluate medical claims for coding and pricing errors using accurate HCPCS, ICD-10, and CPT codes.
4. Research coding rules and guidelines in support of internal and external pre-pay edits.
5. Lookup and review medical claims in payer system to determine methods of payment and validate savings identified.
6. Provide coding expertise on reimbursement policy, provider contractor investigations, and prepay editing topics.
7. Represent team in payment policy discussions and when necessary, and document new policies or modifications to existing policies.
8. Act as a subject matter expert using internal and external tools in order to complete audits and provide guidance to team members.
9. Aid in the training and peer review of others in the department for data mining / coordination of benefits and auditing best practices.
10. Act as a mentor by answering questions regarding contracts, policies, and medical coding.
11. Assist in provider collection efforts and appeal resolution as needed.
12. Prepare comprehensive overpayment white papers and present to client
13. Utilize official coding guidelines and resources as required, including CMS directives and bulletins.
14. Collaborate, coordinate, and communicate across disciplines and departments.
15. Ensure compliance with HIPAA regulations and requirements.
16. Demonstrate Company's Core Competencies and values held within.
17. Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.
18. 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.

COMPENSATION: