This is a fully remote opportunity in OH. Note, quarterly/ad-hoc on-site requirement in Brooklyn, OH.
Responsibilities
Clinical Auditor
Working under general supervision, audits complex outpatient, inpatient and professional claim irregularities, overpayments and provider appeals from a clinical coding perspective, applying coding guidelines. Analyzes provider billing for abnormalities, questionable billing practices and proper coding combinations from a clinical and coding perspective and documents denial reasoning or erroneous activity.
· Audits outpatient, inpatient and professional claims from a clinical and coding perspective applying coding guidelines and edits. Assesses for inappropriate billing combinations, inherent charges, provider supporting documentation, etc.
· Documents audit results including denial reasons, erroneous activities, etc. and updates systems accordingly.
· Maintains knowledge in coding and billing guidelines and trends.
· Reviews provider appeals applying coding guidelines or edits.
· Identifies edits to adjudication system that are not working properly or need to be installed so claims can be processed. Works with more senior levels to implement changes.
· Interacts with internal or external auditors or vendors on claim coding updates, procedure changes, etc.
· Discusses consult findings with Physician Reviewers and reviews edit updates and questions with payment recovery staff.
· Performs other duties as assigned.
Senior Clinical Auditor
Working under limited supervision, audits typically more complex outpatient, inpatient and professional claim irregularities, overpayments and provider appeals from a clinical coding perspective, applying coding guidelines. Analyzes provider billing for abnormalities, questionable billing practices and proper coding combinations from a clinical and coding perspective and documents denial reasoning or erroneous activity.
· Audits outpatient, inpatient and professional claims from a clinical and coding perspective applying coding guidelines and edits. Assesses for inappropriate billing combinations, inherent charges, provider supporting documentation, etc.
· Documents audit results including denial reasons, erroneous activities, etc. and updates systems accordingly.
· Identifies additional opportunities for recovery and avoidance. Researches opportunities to better control medical spending and presents ideas to management.
· Researches and maintains knowledge in coding and billing guidelines and trends. Participates in implementation of new or updated policies and processes.
· Reviews provider appeals applying coding guidelines or edits.
· Identifies edits to adjudication system that are not working properly or need to be installed so claims can be processed. Works with lead or manager to implement changes.
· Orients, trains, assists and reviews work of more junior level staff.
· Interacts with internal or external auditors or vendors on claim coding updates, procedure changes, etc.
· Discusses consult findings with Physician Reviewers and reviews edit updates and questions with payment recovery staff.
· Performs other duties as assigned.
Qualifications
Clinical Auditor
· Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor’s degree preferred.
· In lieu of RN, Bachelor of Science in medical related field.
· 3 years as a Clinical Auditor or equivalent combination of clinical and medical auditing experience.
· Certified Medical Auditor (if not certified required to obtain within 18 months of hire).
· Certified Coder preferred.
· Knowledge of ICD codes.
· Knowledge of procedure codes.
· Knowledge of Revenue Codes, HCPC Codes and CPT codes.
· Knowledge of industry standard billing rules and regulations for professional claims billing, outpatient claims billing and inpatient claims billing.
· Knowledge of insurance regulations.
· Knowledge of coding and auditing techniques.
· Good written communication skills.
· Intermediate Microsoft Office and claims adjudications systems skills.
Senior Clinical Auditor
· Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor’s degree preferred.
· In lieu of RN, Bachelor of Science in medical related field.
· 5 years as a Clinical Auditor or equivalent combination of clinical and medical auditing experience.
· Certified Medical Auditor (if not certified required to obtain within 18 months of hire).
· Certified Coder preferred.
· Strong knowledge of ICD codes.
· Strong knowledge of procedure codes.
· Strong knowledge of Revenue Codes, HCPC Codes and CPT codes.
· Strong knowledge of industry standard billing rules and regulations for professional claims billing, outpatient claims billing and inpatient claims billing.
· Strong knowledge of insurance regulations.
· Strong knowledge of coding and auditing technique.
· Strong written communication skills.
· Intermediate to advanced Microsoft Office and claims adjudications systems skills.
Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That’s why we offer an exceptional package that includes:
A Great Place to Work:
- Top Workplace in Northeast Ohio. Year after year we’ve received this recognition!
- On-site wellness center at most locations. Enjoy personal trainers, locker room, weight room, elliptical machines, and a variety of classes!
- On-site cafeteria serving hot breakfast and lunch, at most locations. Choices ranging from salad bar, made to order, hot and cold sandwiches, or a variety of entrees cooked fresh daily. Convenience store at most locations
- Employee discount program. Discounts at many places in and around town, just for being a Medical Mutual team member
- Business Casual attire
Excellent Benefits and Compensation:
- Competitive compensation plans
- Employee bonus program
- 401(k) with company match and an additional company contribution
- Excellent medical, dental, vision, and disability insurance
An Investment in You:
- Career development programs and classes
- Mentoring and coaching to help you advance
- Education reimbursement up to $5K per year
About Medical Mutual:
We strive to create peace of mind. Our customers can trust us to do things right and to help them get value from their health plan. We’re the largest health insurer in Ohio and for over 85 years, we’ve been serving our members and the Ohio communities where they live and work. Medical Mutual is a Top Place to Work in Northeast Ohio with exceptional career opportunities that offer challenge, growth and a great work/life balance. We want talented, innovative, and driven people to help us continue to be the best health insurance choice of Ohioans and help make Ohio the best it can be! Our headquarter building is located in Brooklyn, OH and we have multiple offices throughout the state. Join us at one near you! APPLY HERE