Responsible for routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory standards and timelines, business policy, contract, appropriate coding, and system configuration. May include physician, outpatient, inpatient, facility, long term services and supports, etc.
High School Diploma or GED.
5-8 years medical claims processing experience, claim adjudication, and coordination of benefit plans.
2-3 years Medicaid/ Medicare audit experience.
Demonstrated ability to analyze benefit issues, claim pricing methodology (Fee Schedule, DRG etc.) and an advanced knowledge of Medicaid claim processing procedures and guidelines.
Advanced knowledge of insurance industry and medical terminology.
Proficiency with Microsoft Office including Outlook, Word, Excel and Access.
Excellent Customer Service Skills with ability to explain complicated benefit issues.
Previous Project Management or Project Coordination experience.
Strong communication skills, both written and verbal.
Strong business acumen with the ability to build and maintain relationships.
Strong analytical skills, with the ability to identify a root cause and come up with solid resolution.