Healthcare Horizons, Inc. is an industry-leader in healthcare claims auditing for self-insured employers. Our clients include companies at the very top of the Fortune 500. We utilize data analytics, clinical expertise, and proprietary methodologies to test claims payment accuracy of third-party administrators (TPA). Our goal is to ensure appropriate administration of the employers’ healthcare plans and to identify any recoverable overpayments to provide a positive return on investment for our clients.
Healthcare Horizons seeks to hire a full-time Sr. Medical Claims Auditor to join our growing team of professionals in the healthcare claims auditing industry. The successful candidate will be a strategic thinker with previous healthcare experience that will contribute to the success of Healthcare Horizons.
Essential Functions:
This self-starter will be focused on analyzing claims data to identify claims processing errors. The healthcare auditor should have experience working with medical claims data along with auditing expertise. Typical duties include, but are not limited to:
- Analyze data to assess the accuracy of claims payments
- Identify trends and anomalies within claims data and perform root cause analysis
- Review plan documents, service agreements, and provider contracts
- Perform virtual site visits with Third-Party Administrators to review claim information
- Communicate audit results in a structured report format within required timelines
- Identify non-routine audit procedures that should be performed
Competencies:
- Perform all job duties in accordance with HIPAA privacy and security rules as it relates to protected health information
- Strong judgment, critical thinking skills are necessary
- Superior written and interpersonal communication skills
- Familiarity with medical terminology and ICD-10, CPT, HCPCS
- Thorough understanding of claims adjudication processes required
- Proficiency with MS Office products
Travel:
This position may require travel, however, most audits are being performed virtually.
PREFERRED EDUCATION AND EXPERIENCE:
- Bachelor’s degree in healthcare or business-related field and/or related work experience
- 5+ years of experience in healthcare environment – preferably with large payer organizations (TPA)
- SQL database experience is helpful
- Collaboration skills
AAP/EEO STATEMENT:
Healthcare Horizons Consulting Group, Inc. is an Equal Opportunity Employer and complies with all applicable laws and regulations regarding equal employment opportunities. The policy of Healthcare Horizons is to apply recruiting, hiring, promotion, compensation, and professional development practices without regard to the race, religion, color, national origin, sex, age, creed, disability, genetic information, veteran status, sexual orientation, or any other characteristic protected by law. Any applicant or employee who believes s/he has a discrimination claim (including harassment or retaliation) must contact Healthcare Horizons’ HR Department within 45 calendar days of the event or action s/he believes to constitute discrimination, harassment, or retaliation.
Please send your resume to hhadmin@healthcarehorizons.com.