Medical Claims Auditor
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Job Description
Medical Claims Auditor responsible for reviewing and analyzing medical claims for accuracy and compliance in healthcare. Collaborating with teams to enhance claim accuracy and reduce errors.
Responsibilities:
- Review medical claims, supporting documentation, and medical records to ensure completeness, accuracy, and compliance with company policies and industry standards
- Validate coding accuracy using ICD-10, CPT, and HCPCS guidelines
- Interpret and analyze Explanation of Benefits (EOB) and UB-04 claim forms to verify correct billing and payment data
- Identify and document discrepancies such as duplicate claims, unbundled services, upcoding, and other billing errors
- Communicate audit findings and recommend corrective actions to the claims processing team or management
- Apply auditing methodologies and regulatory guidelines (CMS, Medicaid, Medicare, and payer contracts) to ensure claims integrity
- Support process improvements to enhance claim accuracy and reduce billing errors
Requirements:
- Minimum of three (3) years of direct medical claims collections experience
- Strong knowledge of insurance policy types (HMO, PPO, EPO, Medicare, Medicaid)
- Advanced understanding of Explanation of Benefits (EOBs) and medical billing forms UB-04 and HCFA-1500
- Experience navigating payer portals and health information systems (e.g., Availity, Navinet)
- Demonstrated ability to perform high-volume outreach and communication
Benefits:
- Flexible vacation policy
- 401(k) employer match
- Comprehensive health benefits
- Educational assistance
- Leadership and technical development academies
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