Medical Claims Auditor

Job Application for Medical Claims Auditor at Point C

Point C is a National third-party administrator (TPA) with local market presence that delivers customized self-funded benefit programs. Our commitment and partnership means thinking beyond the typical solutions in the market – to do more for clients – and take them beyond the standard “Point A to Point B.” We have researched the most effective cost containment strategies and are driving down the cost of plans with innovative solutions such as, network and payment integrity, pharmacy benefits and care management. There are many companies with a mission. We are a mission with a company.

The Medical Claims Auditor is responsible for reviewing and analyzing medical claims to ensure accuracy, compliance with regulations, and adherence to company policies. The Medical Claims Auditor also listens to and evaluates phone calls to measure accuracy and etiquette of Customer Service Representatives. They work closely with the Claims and Customer Service teams to identify errors and areas of development, providing recommendations for process improvements using trend data.

Primary Responsibilities:

• Review and audit medical claims for accuracy and compliance with company policies and benefit plan parameters.
• Listen to customer service phone calls for accuracy and professionalism.
• Provide feedback, coaching, and mentoring to claims and customer service staff members on results, best practices and compliance issues.
• Assist in training efforts as needed.
• Prepare summary and detailed reports on audit findings, trends, and recommendations for process enhancements.
• Stay updated on industry changes in medical coding, billing regulations, and insurance policies.
• Assist in developing and implementing audit policies and procedures.
• Measure and report on performance guarantee results.

Qualifications:

• Minimum of 2 years of experience in customer service or claims processing, preferably within the healthcare or employee benefits industry. Experience with self-funded plans and TPAs is highly desirable.
• Written and Oral Communication Skills: Proven ability to respond to internal customers in a professional, accurate and thorough manner.
• Benefits Expertise: Strong knowledge of benefits plan design and auditing processes as well as medical terminology, ICD-10 and CPT coding.
• Detail-Oriented: Exceptional attention to detail and accuracy in all aspects of research, problem solving and communication.
• Problem-Solving Skills: Ability to analyze issues, identify root causes, and work with management to implement effective solutions in a timely manner.

Benefits:

• Comprehensive medical, dental, vision, and life insurance coverage
• 401(k) retirement plan with employer match
• Health Savings Account (HSA) & Flexible Spending Accounts (FSAs)
• Paid time off (PTO) and disability leave
• Employee Assistance Program (EAP)