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
Qualifications
Qualifications
Required:
- 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
Preferred:
- American Academy of Professional Coder’s (AAPC) COC and/or CIC
- Data analytics experience
- Knowledge of COGNOS reporting environment
Neighborhood Health Plan of Rhode Island 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, disability or veteran status.
Skills Required
- Associate's degree or equivalent three (3) years of claim review work experience
- 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 and innovative thinking
- Strong written and verbal communication skills
- Excellent customer service skills
- Ability to effectively prioritize and execute tasks in a high-pressure environment
- Intermediate to Advanced Microsoft Office skills (Word, Excel, Outlook)
- Ability to work independently and as part of a team
- AAPC COC and/or CIC
- Data analytics experience
- Knowledge of COGNOS reporting environment
What We Do
Neighborhood Health Plan of Rhode Island (NHPRI) is a mission-driven, not-for-profit 501c3 health maintenance organization (HMO) insurance company. The organization provides nationally-recognized, high-quality health insurance and healthcare coverage to over 150,000 residents of Rhode Island, focusing on delivering affordable health care, wellness, and high-quality medical services to its members.
