Health Plan Medical Claims Auditor - Hybrid

We are seeking a detail-oriented and experienced Medical Claims Auditor to join our team. As a Medical Claims Auditor, you will be responsible for reviewing and auditing medical claims to ensure accuracy, compliance with regulations, and adherence to company policies and procedures. You will work closely with the claims processing team to identify discrepancies, resolve issues, and improve overall claims accuracy.

Key Responsibilities 

Conduct audits of medical claims to verify accuracy, completeness, and compliance with regulatory requirements.

Review claim documentation, including medical records and billing codes, to ensure proper coding and billing practices.

Identify errors, discrepancies, and potential fraud or abuse in claims submissions.

Investigate and resolve discrepancies through communication with internal departments, and clients.

Collaborate with the claims processing team to implement process improvements and ensure consistent adherence to company policies and procedures.

Prepare audit reports detailing findings, recommendations, and corrective actions taken.

Stay current with industry regulations, coding guidelines, and best practices related to medical claims processing and auditing.

Qualifications

Bachelor's degree or equivalent experience in healthcare administration, business administration, or a related field.

Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification preferred.

Minimum of 5 years of experience in medical claims processing, billing, or auditing.

Strong understanding of medical terminology, ICD-10, CPT, and HCPCS coding systems.

Knowledge of healthcare regulations, including HIPAA, Medicare, and Medicaid guidelines.

Excellent analytical and problem-solving skills with a keen attention to detail.

Effective communication skills, both verbal and written, with the ability to communicate complex information clearly and concisely.

Proficiency in Microsoft Office applications, especially Excel, and experience with claims processing software preferred.