Job SummaryThis position is responsible for auditing clinical, billing, coding and lowest cost setting reviews for services pre and post payment utilizing medical, contractual, legislative, policy, and other information to validate claims submitted and billed. Conducting research. Preparing documentation of findings and consulting with special investigation and the affordability of care area as needed. Coordinating with all departments involved in each case required such as medical director special investigations, customer service, pass, network management, marketing, case management, medical review, legal, pricing and database.
Required Job Qualifications: - Bachelor's degree; one year of business experience, law enforcement experience, or regulatory agency experience may substitute for each year of college.
- Certified Coding Certification, or acquire within 24 months of hire
- 3 years of experience in claims processing operations and reporting systems, including 2 years of experience in auditing or developing computer system reports.
- Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation.
- Awareness of claims processes and claims processing systems.
- PC proficiency to include Microsoft Word and Excel and health insurance databases.
- Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings.
- Organizational skills and prioritization skills
Preferred Job Qualifications: - Current AAPC Medical Coding Certification
#LI-MW2
#LI-Remote
Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!Pay Transparency Statement:At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.
The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.
Base Pay Range$55,900.00 - $123,500.00
Exact compensation may vary based on skills, experience, and location.
