Medical Claims Investigator

Medical Claims Investigator

United States (Remote)

Job Description

JOB SUMMARY:  
This role reviews medical paid claims against provider contracts and policies to ensure medical payments have been processed accurately. The incumbent will employ data mining and coordination of benefit techniques to analyze and audit hospital and physician claims to identify errant claim payments.  

JOB ROLES AND RESPONSIBILITIES: 

•    Achieve measured production, quality, and growth results.  
•    Utilize analytics and data mining and coordination of benefits techniques to client paid claims data. 
•    Evaluate medical claims for coding and pricing errors using accurate HCPCS, ICD-10, and CPT codes.  
•     Lookup and review medical claims in payer system to determine methods of payment and validate savings identified.  
•   Promote a positive team environment that is based around critical thinking and sharing intelligence to help meet both individual and team goals.  
•    Utilize official coding guidelines and resources as required, including CMS directives and bulletins. 
•     Collaborate, coordinate, and communicate across disciplines and departments. 
•   Ensure compliance with HIPAA regulations and requirements. 
•     Demonstrate Company’s Core Competencies and values held within. 
•     Please note due to the exposure of PHI sensitive data – this role is considered to be a High Risk Role. 
•    The position responsibilities outlined above are in no way to be construed as all encompassing.  Other duties, responsibilities, and qualifications may be required and/or assigned as necessary. 

JOB SCOPE: 
This role keeps the needs of external and internal customers as a priority when making decisions and taking action.  Will work under direct supervision to uncover actionable claims which facilitate savings for customers. Interacts with customers and internal staff in the organization. 

JOB REQUIREMENTS (Education, Experience, and Training): 
•    Minimum high school diploma or GED along with two (2) years of direct experience in medical claims investigation or data mining / coordination of benefits auditing.  Attainment of relevant medical billing and coding certification along with a bachelors’ degree in a relevant field are both highly preferred. 
•    Knowledge of coding type edits and medical claim reimbursement structures and methodologies 
•    Proficiency with medical terminology, medical procedures, medical conditions, and illness and treatment practices 
•    Experience in applying principles of coding guidelines; federal/state regulations and policies pertaining to coding and billing 
•    Knowledge in researching state and federal healthcare guidelines, i.e. Medicare and State Medicaid Programs 
•    Familiarity with automated medical claims payment systems and/or working knowledge of payer systems (i.e. Facets, QNXT, etc.) 
•    Advanced computer skills and proficiency with Microsoft Excel 
•    Must be able to prioritize, coordinate, multitask, think outside the box, and be energetic 
•    Must be able to work independently while maintaining close attention to detail 
•    Required licensures, professional certifications, and/or Board certifications as applicable 
•    Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone

COMPENSATION: 
The salary range for this position is $50k - $55K.  Specific offers take into account a candidate's education, experience and skills, as well as the candidate's work location and internal equity. This position is also eligible for health insurance, 401k and bonus opportunity.

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About Us

Why Claritev?

Healthcare is complex. We help make it clearer.

At Claritev, you'll do work that matters. Together, we're helping make healthcare more transparent and affordable for all through the power of data, technology, and expertise. We offer meaningful opportunities to grow your career, collaborate with talented colleagues, and make an impact on the clients and communities we serve. If you're looking for purpose, growth, and a team that succeeds together, you'll find it here.

What Guides Us

At Claritev, innovation, agility, and a focus on results drive our success. We embrace bold thinking, work as one team, take ownership, and strive for excellence in everything we do — creating meaningful impact for our clients, communities, and each other.

About the Team

My Total Value

Claritev’s global total rewards philosophy — My Total Value — is grounded in investing in our associates and rewarding performance. This includes:

• Competitive compensation and incentive opportunities (where eligible)
• Medical, dental, and vision coverage
• Life and disability coverage
• 401(k) with company match
• Employee stock purchase plan
• Flexible spending accounts and health savings accounts
• Paid time off and company holidays
• Paid parental leave
• Mental health resources
• Tuition reimbursement
• Financial planning resources
• Professional development opportunities

Our Commitment to Inclusion

At Claritev, we believe diverse perspectives strengthen our teams and lead to better outcomes. We are committed to fostering an inclusive workplace where every associate feels respected, valued, and empowered to succeed.

Claritev is an Equal Opportunity Employer and complies with all applicable laws and regulations. Qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by law.

Job Info

• Job Identification516
• Job CategoryClaims Management
• Job ScheduleFull time
• Locations 7900 Tysons Corner Pl., McLean, VA, 22102, US(Remote)