Medical Claims Investigator
At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our purpose is simple - we strive to bend the cost curve in healthcare for all. Our dedication to service excellence extends to all our stakeholders - internal and external - driving us to consistently exceed expectations. We are intentionally bold, we foster innovation, we nurture accountability, we champion diversity, and empower each other to illuminate our collective potential.
Be part of our amazing transformational journey as we optimize the opportunity towards becoming a leading technology, data, and innovation voice in healthcare. Onward and Upward!!!
JOB SUMMARY:
This role reviews medical paid claims against provider contracts and policies to ensure medical payments have been processed accurately. The incumbent will employ data mining and coordination of benefit techniques to analyze and audit hospital and physician claims to identify errant claim payments.
JOB ROLES AND RESPONSIBILITIES:
1. Achieve measured production, quality, and growth results.
2. Utilize analytics and data mining and coordination of benefits techniques to client paid claims data.
3. Evaluate medical claims for coding and pricing errors using accurate HCPCS, ICD-10, and CPT codes.
4. Lookup and review medical claims in payer system to determine methods of payment and validate savings identified.
5. Promote a positive team environment that is based around critical thinking and sharing intelligence to help meet both individual and team goals.
6. Utilize official coding guidelines and resources as required, including CMS directives and bulletins.
7. Collaborate, coordinate, and communicate across disciplines and departments.
8. Ensure compliance with HIPAA regulations and requirements.
9. Demonstrate Company's Core Competencies and values held within.
10. Please note due to the exposure of PHI sensitive data, this role is considered to be a High Risk Role.
11. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.
JOB SCOPE:
This role keeps the needs of external and internal customers as a priority when making decisions and taking action. Will work under direct supervision to uncover actionable claims which facilitate savings for customers. Interacts with customers and internal staff in the organization.
Apply Now
Be part of our amazing transformational journey as we optimize the opportunity towards becoming a leading technology, data, and innovation voice in healthcare. Onward and Upward!!!
JOB SUMMARY:
This role reviews medical paid claims against provider contracts and policies to ensure medical payments have been processed accurately. The incumbent will employ data mining and coordination of benefit techniques to analyze and audit hospital and physician claims to identify errant claim payments.
JOB ROLES AND RESPONSIBILITIES:
1. Achieve measured production, quality, and growth results.
2. Utilize analytics and data mining and coordination of benefits techniques to client paid claims data.
3. Evaluate medical claims for coding and pricing errors using accurate HCPCS, ICD-10, and CPT codes.
4. Lookup and review medical claims in payer system to determine methods of payment and validate savings identified.
5. Promote a positive team environment that is based around critical thinking and sharing intelligence to help meet both individual and team goals.
6. Utilize official coding guidelines and resources as required, including CMS directives and bulletins.
7. Collaborate, coordinate, and communicate across disciplines and departments.
8. Ensure compliance with HIPAA regulations and requirements.
9. Demonstrate Company's Core Competencies and values held within.
10. Please note due to the exposure of PHI sensitive data, this role is considered to be a High Risk Role.
11. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.
JOB SCOPE:
This role keeps the needs of external and internal customers as a priority when making decisions and taking action. Will work under direct supervision to uncover actionable claims which facilitate savings for customers. Interacts with customers and internal staff in the organization.
Apply Now