Medical Claims Investigator

Job Summary

To support a dynamic healthcare team, the full-time Medical Claims Investigator will review medical paid claims against provider contracts, employing data mining techniques to analyze and audit claims for accuracy while ensuring compliance with regulations.

Key responsibilities

• Utilize analytics and data mining techniques to evaluate client paid claims data
• Assess medical claims for coding and pricing errors using HCPCS, ICD-10, and CPT codes
• Collaborate across departments to promote a positive team environment focused on achieving individual and team goals

Required qualifications

• Minimum high school diploma or GED with two years of experience in medical claims investigation or data mining
• Preferred attainment of relevant medical billing and coding certification and a bachelor's degree in a related field
• Knowledge of coding type edits and medical claim reimbursement structures
• Familiarity with automated medical claims payment systems and payer systems
• Advanced computer skills, particularly proficiency with Microsoft Excel