Senior Medical Claims Audit & Revenue Integrity Specialist

Location: Remote
Work Arrangement: 100% Remote
Schedule: Flexible based on receipt of claim details
Interview: Virtual
Contract: Approximately 80 hours, plus potentially 16-24 additional hours of assistance while the claims population is generated and the detailed sample is pulled

Role Overview

CLA is seeking a Senior Medical Claims Audit & Revenue Integrity Specialist to support a 100% remote medical claims engagement for the State of Arizona. The role requires an advanced billing, coding, or clinical background in medical claims and focuses on reviewing claim accuracy and appropriateness.

The work includes ICD-10 coding, procedure and diagnosis codes, claim pricing, contractual requirements, prior authorization and referral requirements, coverage provisions, subrogation, upcoding, and medical necessity.

Primary Responsibilities

• Confirm the accuracy of ICD-10 claim coding against contract rates and terms.
• Validate that claim coding and detail are consistent with procedure and diagnosis codes.
• Verify if prior authorization, referrals, and related requirements are needed for various claim types.
• Confirm the accuracy of claim pricing related to contract terms and requirements.
• Determine alternative, less expensive treatments or codings that may apply given the nature of the procedure or diagnosis and determine that upcoding does not exist.
• Validate whether subrogation of claims is present, appropriate, and applicable.
• Determine whether coverage caps, annual limits, and related requirements are applied correctly depending on contract and treatment.
• Perform a reasonability check of medical necessity and applicability given medical notes and details.

Required Technical Skills

• Advanced billing, coding, or clinical background in medical claims.