Job Description

The primary role of the CLAIMS AUDITOR is to review, identify and validate claim overpayments. Types of overpayment reviews will include, but are not limited to: Duplicate Payment, Contract Compliance, Authorizations, Eligibility, Coordination of Benefits, Medical Review, DRG Review, Medicare and Medicaid reimbursement policies.

CLARISHEALTH IS THE ANSWER TO THE HEALTH PLAN INDUSTRY’S SILOED SOLUTIONS AND TRADITIONAL MODELS FOR IDENTIFICATION AND OVERPAYMENT RECOVERY SERVICES. FOUNDED IN 2013, WE PROVIDE HEALTH PLANS AND PAYERS WITH TOTAL VISIBILITY INTO PAYMENT INTEGRITY OPERATIONS THROUGH OUR ADVANCED COST CONTAINMENT TECHNOLOGY PAREO®. PAREO ENABLES HEALTH PLANS TO MAXIMIZE AVOIDANCE AND RECOVERIES AT THE MOST OPTIMIZED COST FOR A 10X RETURN ON THEIR SOFTWARE INVESTMENT. CURRENTLY, NEARLY 33 MILLION LIVES ARE SERVED BY OUR TOTAL PAYMENT INTEGRITY PLATFORM.

ClarisHealth embraces a working culture of transparency and innovation, termed internally as “Got Your Back”. Our strong Cultures program operates on 5 core values: Innovation, Compassion, Integrity, Communication, and Accountability. For more information on our culture and employment opportunities, please visit us at https://www.clarishealth.com/careers/.

RESPONSIBILITIES

The essential functions include, but are not limited to the following:

• Work with team members to ensure project goals are met in an efficient and effective manner.
• Achievement of individual productivity and quality goals.
• Communicate to management any issue(s) that would impede the accurate and timely review of claims. Work with management to ensure that these issues are resolved.
• Give feedback to management regarding query effectiveness and new query ideas.
• Acquire knowledge of the client’s claims adjudication system, provider contracts as well as basic client claim payment policies and procedures. Communicate with management issues that may affect the review of claims.
• Communicate any discrepancies of the client’s data as loaded in the data mining internal system.
• Validate claims to ensure the accuracy of query results and that no refund has previously been posted to clients’ systems.
• Work with management on clarification of matters as they arise through the course of review.
• Inform manager of trends discovered in the review and validation process.
• Contact appropriate parties to confirm that a valid claim has been identified. This could include but not limited to Providers, Members, and/or Other Health Insurance Carriers.
• May work with Accounts Receivable staff to research and/or answer questions from providers regarding overpayments.

MEASURES OF SUCCESS

• Meet monthly performance goals
• Ability to collaborate with external teams and effectively communicate message

REQUIREMENTS

• 2-3 YEARS PREVIOUS MEDICAL CLAIM AUDITING EXPERIENCE
• MUST HAVE WORKING KNOWLEDGE OF EXCEL
• WORKING KNOWLEDGE OF THE BASIC PRINCIPLES OF TERMINOLOGY IN HEALTHCARE
• REQUIRES WORKING KNOWLEDGE OF INDUSTRY REIMBURSEMENT STANDARDS, PAYER/PROVIDER CONTRACTING AND CLAIMS PROCESSING PROTOCOLS.
• WORKING KNOWLEDGE OF DRG, CPT AND REVENUE CODES AND HOW CLAIMS SHOULD BE REIMBURSED
• Strong organizational skills
• Excellent verbal and written communication skills.
• Ability to work well in an individual and team environment.
• Reliable transportation and High School degree required

ClarisHealth is an Equal Opportunity Employer. Anyone needing accommodation to complete the interview process should notify the Director, People & Management.

EOE including Disability/Veterans/