Medical Claims Auditor

BCforward is currently seeking a highly motivated Remote Medical Claims Examiner.

Position Title: Medical Claims Auditor

Location: Remote

Anticipated Start Date: Tentative start Date 05/16/2024
Please note this is the target date and is subject to change. BCforward will send official notice ahead of a confirmed start date.

Expected Duration: 06 months Contract with a strong possibility of extension

Job Type: Contract (40 HRS WEEKLY), [CONTRACT], [REMOTE]

Pay Range: $15/hr - $20/hr
Please note that actual compensation may vary within this range due to factors such as location, experience, and job responsibilities, and does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).

Requirements:
Claims Auditing, Examiner, HIPAA, Claims Processing

Job Description:

• Carefully examine medical claims documentation, including medical records, bills, and supporting documents, to verify the accuracy and completeness of information submitted by healthcare providers.
• Apply appropriate coding guidelines (e.g., ICD-10, CPT, HCPCS) to ensure that diagnoses, procedures, and services are correctly coded, in accordance with industry standards and regulatory requirements.
• Validate the appropriateness of claims based on established policies, contracts, and medical guidelines.
• Identify any discrepancies or inconsistencies and appropriately communicate them for further investigation.
• Identify and investigate potential billing errors, such as duplicate claims, unbundling, upcoding, and incorrect coding combinations.
• Report findings to the Claims Manager or designated supervisor.
• Monitor claims processing activities to ensure adherence to legal and regulatory requirements, such as HIPAA, CMS guidelines, and contractual obligations.
• Document audit findings, maintain accurate records, and generate comprehensive reports summarizing audit results, trends, and recommendations for process improvement.
• Collaborate with internal stakeholders, including claims processors, billing specialists, and healthcare providers, to resolve claim-related issues, provide guidance on coding requirements, and address any questions or concerns.
• Stay up-to-date with changes in coding guidelines, industry regulations, and best practices.
• Participate in training sessions and professional development activities to enhance knowledge and skills.
• Assist in the implementation and maintenance of quality assurance processes to ensure the accuracy, integrity, and efficiency of claims processing operations.
• Contact providers to obtain additional information and/or documentation to resolve unpaid claims, as directed.
• Respond to carrier telephone, fax, and e-mail inquiries regarding outstanding claims
• Confer with carriers by telephone or use portals/ websites to determine member eligibility and claim status.
• Update case management system with proper noting of actions and appeal/ denial information.
• Generate form letters to carriers to affect payment of outstanding claims.
• Leverage RCM knowledge to assess denials, pursue appeals, or close claims when appropriate.
• Work with document imaging system for processing purposes.
• Responsible for achieving high recoveries against a portfolio of claims.
• Responsible for achieving daily, monthly, and quarterly quality and productivity KPIs.

Non-Essential Responsibilities

• Performs other functions as assigned

Knowledge, Skills, and Abilities

• Proven experience in medical claims processing, medical billing, or coding, preferably in an auditing capacity.
• Strong understanding of third-party billing and/or claims processing.
• Strong knowledge of medical terminology, anatomy, physiology, and ICD-10, CPT, and HCPCS coding systems.
• Familiarity with healthcare regulations, including HIPAA, CMS guidelines, and insurance policies.
• Proficient in using medical billing software and coding databases.
• Excellent analytical and problem-solving skills with a keen attention to detail.
• Effective communication skills, both verbal and written, to interact with internal teams and external stakeholders.
• Ability to work independently, prioritize tasks, and meet deadlines.
• Strong ethical standards and understanding of confidentiality requirements.
• Continuous learning mindset and willingness to stay updated with industry changes.
• Ability to perform basic mathematic calculations.
• Ability to work proficiently with Microsoft Windows, and Word and have intermediate-level knowledge of Excel.
• Average manual dexterity in the use of a PC, phone, sorting, filing, and other office machines.
• Ability to perform well in a team environment, with staff at all levels, to achieve business goals.
• Possess excellent customer service skills.
• Ability to work independently to meet predefined production and quality standards.

Work Conditions and Physical Demands

• Primarily sedentary work in a general office environment
• Ability to communicate and exchange information
• Ability to comprehend and interpret documents and data
• Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)
• Requires manual dexterity to use computer, telephone, and peripherals
• May be required to work extended hours for special business needs
• May be required to travel at least 10% of the time based on business needs

Minimum Education
High School Diploma or equivalent required.
Some college coursework (with a concentration in healthcare, medical billing, or coding field) or a degree in a related field is preferred.
Associate's Degree Preferred.

Certifications (Required/Desired)
Certification in medical billing/coding (e.g., CPC, CCS) is preferred

Minimum Related Work Experience

• 5-7 yrs. experience with third-party collections
• 3yr experience handling appeals claims in a hospital setting, Ability to interpret an Explanation of Benefits (EOB) and UB-04 claim form required. DSM-IV, CPT, HCPCS, and CMS-1500 preferred
• Working knowledge of Access and SQL is also preferred.

Keywords:
Claims Auditor, Claims Examiner, Claims Specialist

Who to Contact: Priyanka Samindla

About BCforward:
Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.
BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.
BCforward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.
To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.
This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.

Interested candidates please send resume in Word format Please reference job code 222169 when responding to this ad.