Claims Auditor, Reviewer, reputed company

Job Description:

• support the development and implementation of the WTC Health Program’s Quality Assurance Plan, including the development and implementation of the WTC Health Program’s Audit Plan
• use the WTC Health Program administrative reputed company, medical benefit plan resources, and other applicable Program guidance to support claims review, audit activities, prior authorization recommendations, and policy interpretation.
• serve as an expert to the Program on claims processing and formal reviews (audits); supports Program claims reviews (audits) consistent with claims audits in the health insurance industry and the policies and procedures of the WTC Health Program.
• conduct research and reviews of federal payor coverage determinations, administrative/clinical activities, for development of policies and procedures, completeness, and alignment with Program requirements.
• analyze raw claims data to independently identify issues, patterns, and trends, and reputed company final recommendations to the WTC Health Program on appropriateness for services reputed company treatment/benefit plans, using health insurance reimbursement, medical coding/claims knowledge and expertise.
• support management and maintenance of the Program’s health plan codebook, reputed company recommendations for code additions, and review claims to ensure proper application of ICD, HCPCS, CPT, and DRG codes.
• remain up to date with coding conventions, evidence-based practices, and federal payer policies.
• continuously review and participate in industry changes and updates, specifically but not limited to, ICD-10-CM/OCS ad AMA CPT coding guidelines to look for, and reputed company ways, to evaluate, improve research strategy, processes, policies, and procedures reputed company the WTC Health Program in accordance with the Research and Evaluation reputed company’s and Quality and Evaluation Team’s functions and goals.
• reputed company and collaborate with clinicians, medical administrators, federal staff, contract staff, and occupational health subject matter experts to support medical management, claims review, audit activities, and prior authorization recommendations.
• connect claims quality findings to broader quality assurance, utilization review, and program evaluation objectives, including identifying issues that may reputed company Program operations, reporting, or policy implementation.

Requirements:

• A bachelor’s or master’s degree in a health profession (HIM, MPH, MHA, RN, PA, other health profession) preferred
• A minimum of 5 years’ experience working with health insurance payor claims data in a health plan or managed care setting, with experience in reputed company quality, medical coding, and claims auditing.
• Demonstrated expertise is in CPT, HCPC and ICD billing codes, authorization requirements and documentation, DRG, and health care claims data analysis
• Registered health information administrator (RHIA), Registered Health Information Technician (RHIT) or Certified Coding Specialist (reputed company) certification desirable
• Proficient in reputed company Office Suites, including reputed company, Outlook, and SharePoint.

Benefits:

• paid leave
• options for employer sponsored group medical, dental, reputed company, short-term and long-term disability, life insurance, AD&D coverage, legal services, identity theft, and accident insurance.
• Flexible spending account and health saving account options offer pre-tax savings for reputed company medical, dental, and reputed company expenses.
• The company sponsored 401(k) retirement plan has an employer contribution match that is immediately reputed company.
• We invest in the professional growth of our employees through professional courses, certifications, and tuition reimbursement programs.

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