Claim Auditor Payment Integrity (44544)
On-site · Smithfield, Rhode Island, United States
Job Summary
Audits claims for payment integrity, investigates overpayments, performs data-driven claim payment evaluations, medical chart reviews, and data analysis to identify overpayments and ensure adherence to billing and reimbursement guidelines. Independently analyzes, extracts, refines, and interprets claims data to deliver actionable insights; develops reports and savings analyses; identifies new audit areas via data mining; collaborates with Payment Integrity team to communicate audit outcomes and recommend policy or guideline modifications. Represents the company in meetings to discuss audit results and provide education on coding and reimbursement practices. Requires an Associate’s degree or equivalent 3 years of claim review experience and CPC certification (or similar experience), Medicare/Medicaid knowledge, strong communication and problem-solving skills, and proficiency with Microsoft Office.
Required Qualifications
- Associate’s degree or equivalent three (3) years of claim review work experience to equate to the degree
- American Academy of Professional Coder’s (AAPC) CPC certification or similar experience in medical records review, claims processing or utilization/case management in clinical practice or managed care organization
- Fundamental knowledge of Medicare/Medicaid Guidelines
- Experience with provider payment methodologies
- Critical thinking and judgment/decision making skills
- Solutions oriented-positive attitude
- Independent problem solving-innovative thinker
- Strong communication skills (written/verbal)
- Excellent Customer Service skills
- Ability to effectively prioritize and execute tasks in a high-pressure environment
- Intermediate to Advanced skills in Microsoft Office (Word, Excel, Outlook)
- Ability to work independently as well as part of a team
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