Claim Auditor Payment Integrity (44544)

The Claim Auditor in Payment Integrity will address problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters. Claim payment accuracy will be recognized through sound audit review methods and practices, including but not limited to; claim payment evaluation, medical chart review, claim payment data analysis and assessment of established organizational contractual parameters. Independently analyzes, extracts, refines, and interprets claims data for actionable insights. The Auditor uses self-directed, decision making and problem solving that directly impacts financial outcomes and results.

Duties and Responsibilities:

Responsibilities include, but are not limited to:

• Investigate potential over-utilization by performing audits thought pre and post claim payment.
• Initiate and verify claims adjustments, maintain audit documentation, and prepare savings reports.
• Identify new audit areas through data mining and performing sample audits.
• Develops reports and deliverables for management and communicates with all levels of stakeholders.
• Provide recommendations and collaborate with Payment Integrity team on audit outcomes, identified issues, recommended modifications to clinical medical policies, billing and reimbursement guidelines, and online provider manual.
• Serve as contact with all operational areas relevant to Payment Integrity audit decisions.
• Represent company in internal and external meetings/conference calls when needed to discuss audit results or perform coding education.
• Performs other duties as assigned