Senior Medical Claims Investigator

Job Summary

To support healthcare cost management, the full-time Senior Medical Claims Investigator will review medical claims against provider contracts, utilize data mining techniques to identify payment discrepancies, and assist in mentoring junior team members while ensuring compliance with coding and reimbursement policies.

Key responsibilities

• Review and analyze medical claims for accuracy, identifying coding and pricing errors
• Utilize data mining techniques to develop algorithms for uncovering savings opportunities in paid claims data
• Assist in training and mentoring junior staff on auditing best practices and coding regulations

Required qualifications

• Minimum high school diploma or GED with four years of experience in medical claims investigation or data mining
• Advanced knowledge of medical coding, reimbursement structures, and federal/state regulations
• Expertise in COB NAIC Guidelines and medical contract interpretation
• Proficiency with automated medical claims payment systems and Microsoft Excel
• Relevant medical billing and coding certification and a bachelor's degree in a related field are preferred