- The Sr. Claims Auditor utilizes CPT and ICD-10 coding to review physician claims and medical records for coding accuracy.
- Internal auditing functions focus on "desktop reviews" of claims, design and quality control of future audits, and other auditing related functions.
- Review clinical notes and claims submitted to verify the appropriateness of codes billed based on services documented / rendered for both institutional and professional claims. Provides timely claims payment decisions based on review.
- Work cooperatively with other departments to obtain required documentation to complete clinical notes review.
- Communicate with hospital or provider staff regarding correct coding where inconsistencies in documentation for services provided are identified. Work with Provider Audit Manager for formal correspondence to providers.
- Review and analyze facility and professional claims against MGBHP's policies and CMS guidelines. Apply knowledge and experience during decision-making process. Complete and document audits based on established guidelines.
- Identify and provide analytical data on billing trends/issues for potential areas of recoveries.
- Lead department efforts to select and implement new claims edits created by software and vendors. Analyze results from editing software and offer recommendations for changing rules.
- Regularly reviews to identify enhancement to the audit methodology and documentation requirements.
- Serves as a coding resource for the Provider Audit team and other departments to interpret and explain coding guidelines as needed.
- Support internal customers by answering questions about policies/guidelines.
- Provide input on and research of claims challenged by the providers.
- Works with Manager of Payment Integrity to develop and implement selection methodology and assist testing new prepay audit implementations.
- Assist with selection of audit criteria based on historical findings or new coding rules. Assist with the assignment and pricing of unlisted codes, and Audit related appeals. Regularly review to identify enhancement to the audit methodology and documentation requirements.
- Identify potential audit concepts and notify Manager of Payment Integrity of any leads, in support of next steps or escalation to outside agencies.
- Serves as a coding resource for the Provider Audit team and other departments to interpret and explain coding guidelines as needed.
- Work with other departments to obtain required documentation to complete medical records review.
- Other duties as assigned with or without accommodation.
- Required to possess Certified Professional Coder (CPC) certification or CCS (Certified Coding Specialist)
- 2+ years of direct auditing experience in a Managed Care environment
- High School diploma required. Associates or Bachelors degree preferred or the equivalent combination of training and experience, plus 3-5 years of related experience
- 4+ of coding experience in Managed Care, medical billing, facility or physician environment required.
- 2+ years of direct auditing experience in a Managed Care environment
- Thorough knowledge of ICD-10, CPT, HCPS, and Revenue Billing Codes.
- Ability to write clearly and succinctly in a variety of communication settings and styles
- Excellent communication and presentation skills across various levels and through multiple channels (oral, written, conversational)
- Strong quantitative and analytical skills
- Ability to apply expertise in various training formats.
-
Claims Auditor
1 week ago
Alan Gray LLC Boston, United StatesJob Description · Job DescriptionBackground · Alan Gray LLC is a leading audit and advisory firm with over 30 years of excellence in providing a range of services to insurance-industry clients. Our goal is to help our clients realize significant bottom-line savings. Our experien ...
-
Senior Claims Auditor
1 week ago
AllWays Health Partners Somerville, United StatesThis is a remote position that can be done in most US states. · Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated h ...
-
Accounts Receivable Manager
1 week ago
Sancta Maria Nursing Facility Cambridge, United States**A/R MANAGER** · Sancta Maria Nursing Facility is seeking a full-time Accounts Receivable Manager to assist the Finance Director with the day-to-day operation of our business office. · - **Duties include**:_ · Directs processing of accounts receivable, adjustments/refunds, priva ...
-
Underwriting Assistant
3 days ago
Coverys Boston, United StatesPosition Summary · The Underwriting Assistant supports the underwriting team with data entry, processing submissions, customer service, and assigned projects. In addition, the Underwriting Assistant will provide administrative support to the Underwriting team, maintain files, and ...
-
Business Office Manager
2 days ago
Parkway Health and Rehabilitation Center Boston, United States**Responsibilities include**: · - Attends A-team meetings, approves financial screening of all new admits, enters census data, meets with residents and families to discuss financial obligations and patient liability, maintains financial files. · - Balances daily census including ...
-
Director of Project Controls
2 days ago
Massachusetts Bay Transportation Authority Boston, United States**Salary** · - $102, $130,000.00 Annually**Location** · - 10 Park Plaza, Boston**Job Type** · - Full-Time**Job Number** · **Department** · - MBTA - General Manager**Area** · - 002-Quality Compliance & Oversight**Opening Date** · - 05/13/2024**Closing Date** · - 5/27/2024 11:59 PM ...
-
Compliance Officer
4 days ago
Brockton Neighborhood Health Center Brockton, United States**Compliance Officer** · **$75, $87,250.00** · **Reports to: Director of Quality & Compliance** · ***: · **RESPONSIBILITIES**: · - Develops, implements, and maintains policies, procedures, and protocols to ensure compliance with all federal, state and local regulations, as well a ...
-
Senior Director of Credit Administration
1 week ago
Root Capital Cambridge, United StatesReports To: Chief Credit Officer · Job Type: Full-Time Employment · Region: · Africa · - Central America & Mexico · - United States · Location: US Remote, MA Cambridge, Costa Rica, Kenya · Start Date: Immediate · Contact: Please apply by using the form below. · About Root C ...
-
Director, Patient Financial Services
6 days ago
Beth Israel Lahey Health Charlestown, United StatesWhen you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives. · Job Type: · Regular · Scheduled Hours: · 40 · Work Shift: · Day (United States of America) · Under oversight of the Executive Director, the Director, BILH Patient Fi ...
-
Remote Virtual Training Consultants
2 weeks ago
firstPRO, Inc Boston, MA, United StatesRole: Consultant · Company: Financial consulting · Location: Downtown Boston - hybrid schedule · A 20-plus year Consulting firm focused on litigation support and consulting to law firms as well as valuations are looking for a top-tier Consultant to join their team. · This per ...
-
Vice President of Enterprise Risk Management
2 weeks ago
Blue Cross Blue Shield of Massachusetts Boston, MA, United StatesReady to help us transform healthcare? Bring your true colors to blue. · Reporting to the Senior Vice President of Risk and Audit Management, the Vice President of Enterprise Risk Management provides leadership to ensure the optimal design and alignment of all risk management fu ...
-
Vice President of Enterprise Risk Management
3 weeks ago
Blue Cross Blue Shield of Massachusetts Boston, United States Full timeReady to help us transform healthcare? Bring your true colors to blue. · Reporting to the Senior Vice President of Risk and Audit Management, the Vice President of Enterprise Risk Management provides leadership to ensure the optimal design and alignment of all risk management fun ...
-
Director of Tax
4 days ago
Madrigal Pharmaceuticals Inc Watertown, United StatesWe are seeking a Director of Tax with experience to lead our tax strategy, compliance, and oversight. This role is pivotal in shaping our tax strategy and offers the chance to expand into broader finance management responsibilities, including oversight of payroll and other functi ...
-
Director of Tax
6 days ago
Madrigal Pharmaceuticals Inc Waltham, United StatesJob Description · Job Description · We are seeking a Director of Tax with experience to lead our tax strategy, compliance, and oversight. This role is pivotal in shaping our tax strategy and offers the chance to expand into broader finance management responsibilities, including ...
-
Director of Tax
5 days ago
Madrigal Pharmaceuticals Corporation Waltham, United StatesJob Description · Job DescriptionWe are seeking a Director of Tax with experience to lead our tax strategy, compliance, and oversight. This role is pivotal in shaping our tax strategy and offers the chance to expand into broader finance management responsibilities, including over ...
-
Accountant
3 days ago
Tokio Marine HCC Wakefield, United StatesHave you recently or will you soon receive a degree in Accounting or Finance and aren't sure what you want to do with your education? · This is not your typical accounting role, trust me. · Do you want to be involved in working on accounting transactions for some cool and interes ...
-
Staff Accountant
1 week ago
Tokio Marine HCC Wakefield, United States· Position at Tokio Marine HCC · Do the sports and entertainment industries pique your interest? · Can you picture yourself joining a market leader in providing specialized disability and event cancellation insurance products to those industries? · If you answered yes to the ...
-
Accountant
2 days ago
Tokio Marine HCC Wakefield, United States· Position at Tokio Marine HCC · Have you recently or will you soon receive a degree in Accounting or Finance and aren't sure what you want to do with your education? · This is not your typical accounting role, trust me. · Do you want to be involved in working on accounting t ...
-
Accountant
4 days ago
Tokio Marine HCC Wakefield, United StatesHave you recently or will you soon receive a degree in Accounting or Finance and aren't sure what you want to do with your education? · This is not your typical accounting role, trust me. · Do you want to be involved in working on accounting transactions for some cool and inter ...
-
Staff Accountant
2 weeks ago
Tokio Marine HCC Wakefield, United StatesDo the sports and entertainment industries pique your interest? · Can you picture yourself joining a market leader in providing specialized disability and event cancellation insurance products to those industries? · If you answered yes to the above questions, then this role is ...
Senior Claims Auditor - Somerville, United States - Brigham and Women's Hospital
Description
Job Description - Senior Claims AuditorSenior Claims Auditor
(
Job Number:
)
This is a remote position that can be done in most US states.
Mass General Brigham Health Plan is an exciting place to be within the healthcare industry.
As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems.
Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.
Our work centers on creating an exceptional member experience – a commitment that starts with our employees.Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.
We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.
Under the general direction of the Manager of Payment Integrity, the Sr. Claims Auditor performs accurate and timely reviews of medical claims for internal audits. The Sr. Claims Auditor reviews detailed medical claims data, medical records, reference materials, provider contracts, medical policies, and payment policies. The Sr.Claims Auditor will be the primary point of contact for issue resolution regarding internal audits between Mass General Brigham Health Plan and the provider community, as well as for coding knowledge within the Provider Audit team.
Additionally, the Senior Claims Auditor will assist in preparing audit reports, including vendor and project summaries.Principal Duties and Responsibilities:
Qualifications:
