medical claims auditor

Meds Nexus Pvt. Ltd.

<div>
 <p>
  A Medical Billing Auditor is responsible for reviewing medical billing processes to ensure accuracy, compliance, and proper reimbursement. They identify errors, prevent revenue loss, and ensure adherence to healthcare regulations.
 </p>
 <p>
  <br/>
 </p>
 <p>
  Job Description:
 </p>
 <ul>
  <li>
   Review and audit medical claims for accuracy and completeness
  </li>
  <li>
   Verify CPT, ICD-10, and HCPCS coding compliance
  </li>
  <li>
   Identify billing errors, fraud risks, or revenue leakage
  </li>
  <li>
   Ensure compliance with payer guidelines and healthcare regulations
  </li>
  <li>
   Analyze denied or rejected claims and suggest corrective actions
  </li>
  <li>
   Provide feedback and training to billing teams
  </li>
  <li>
   Prepare audit reports and maintain documentation
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  Qualification:
 </p>
 <ul>
  <li>
   Strong knowledge of medical billing and coding systems
  </li>
  <li>
   Familiarity with insurance guidelines (Medicare/Medicaid, commercial payers)
  </li>
  <li>
   Attention to detail and analytical thinking
  </li>
  <li>
   Experience with billing software and EHR systems
  </li>
  <li>
   Good communication and reporting skills
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  How to apply:
 </p>
 <p>
  * Send your CV: careers@medsnexus.com
 </p>
 <p>
  * Walk-in interviews are now open &ndash; Apply today!
 </p>
 <p>
  * Location: Office: #1, Top Floor, Gold Mark Plaza, Asghar Mall Scheme, Asghar Mall Road, Rawalpindi
 </p>
 <p>
  <br/>
 </p>
 <p>
  Join us where expertise is valued, performance is rewarded, and growth is continuous.
 </p>
 <p>
  If you&rsquo;re experienced in medical billing, RCM, credentialing, or healthcare sales, 𝐌𝐞𝐝𝐬 𝐍𝐞𝐱𝐮𝐬 is the right place for your next career move
 </p>
 <p>
  <br/>
 </p>
</div>


Medical Billing Auditor

Elevance Health

<div><p><b>Provider Auditor Senior</b> <b>-</b> <b>Audit</b></p><p></p><p><b>
Location: Atlanta, GA; Norfolk, VA &amp; Indianapolis, IN</b></p><p><b>
Hybrid 1:</b> This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.</p><p></p><p><i>
Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.</i></p><p></p><p>
The <b>Provider Auditor Senior</b> conducts on-site reviews of medical charts, medical notes, itemized bills and providers contracts to ensure that a claim is paid in accordance with the contract, provider reimbursement policies, and industry standards.</p><p></p><p><b>
How you will make an impact:</b></p><ul><li>
Selects providers to be reviewed based on historical results of other reviews with providers, network management input and dollar volume of provider.</li><li>
Schedules review with provider, analyzes data to select claims to be reviewed, conducts review using medical charts, medical notes, itemized bills and provider contracts.</li><li>
Conducts exit interview with provider management team by presenting preliminary review results.</li><li>
Verifies dollar amount on claim is correct in claims system and writes report of the findings of the review and requests payments for any overpayments.</li><li>
Identifies aberrant patterns of billing and detects potential abuse.</li><li>
Mentors and trains Provider Auditor as needed.</li><li>
Drafts department policies and procedures and other educational materials.</li><li>
Works on task forces and committees representing functional area.</li></ul><p></p><p><b>
Minimum Qualifications:</b></p><ul><li>
Requires a BA/BS degree and a minimum of 3 years equivalent work experience; or any combination of education and experience, which would provide an equivalent background.</li></ul><p></p><p><b>
Preferred Skills, Capabilities and Experiences:</b></p><ul><li>
Certification as a Professional Coder preferred.</li></ul><br>
<p></p>
<p>Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.</p>
<p>Who We Are</p>
<p>Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.</p>
<p>How We Work</p>
<p>At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.</p>
<p>We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.</p>
<p>Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.</p>
<p>The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.</p>
<p>Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.</p>
<p>Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.</p><p>
Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.</p></div>

Provider Auditor Senior

EXL Service

<div><p>Job Description: In this fully remote position as an HCD Auditor you will apply your expert knowledge of billing HCD claims to perform extensive audit reviews. You will utilize HCPCS codes, medical record review, industry and EXL proprietary tools in the audit process. Write professional communications documenting audit findings and supporting rationales. You will also apply your extensive industry knowledge to identify audit trends and opportunities.</p></div>
<br><div><ul><li>Responsibilities: Conduct HCPCS coding reviews to verify the accuracy of the coding assignment and reimbursement on high cost drug professional and outpatient facility claims.
</li><li>Apply complex medical record reviews to identify discrepancies between physician orders, nursing administration logs, and final claims submissions.
</li><li>Apply Medicare, Medicaid, and commercial guidelines to a variety of claim scenarios and effectively utilize industry and proprietary tools to maximize overpayment identifications.
</li><li>Document audit results in a clear, concise, and effective manner using AMA Guidelines.
</li><li>Utilize proprietary workflow systems to make audit determinations, generate audit rationales, and move claims through workflow process correctly efficiently and accurately.
</li><li>Accurately reprice complex claims utilizing multiple client claims systems.
</li><li>Meet or exceed EXL established program productivity and quality goals, including uphold rate for appeals.
</li><li>Research prescribed drug dosage and related conditions to ensure appropriateness of medical guidelines and accuracy of reimbursement.
</li><li>Comply with all EXL policies and procedures including HIPAA and other state and federal regulations.</li></ul></div>
<br><div><p><b>Qualifications: Required Qualifications
</b></p><ul><li>Three or more years' experience in claims processing or HCD medical billing experience with expert knowledge HCPCS codes.
</li><li>Experience reading and interpreting contract language and fee schedules and medical record review.
</li><li>Intermediate skills in Word and basic computer literacy.
</li><li>Intermediate skills in Excel including comfort working with charts, graphs, and percentages.
</li><li>Basic math skills with ability to do conversion calculations.
</li><li>High school diploma obtained
</li></ul><p><b>Preferred Qualifications
</b></p><ul><li>Certified Pharmacy Technician or one or more of the following credentials: RHIA or CPC; preference given to those with multiple credentials.
</li><li>Expert in HCPCS codes with advanced knowledge of medical terminology.
</li><li>Experience with encoder tools and industry systems (FACETS, NASCO, Encoder Pro, TrueCode, 3M, Webstrat, Pricers).
</li></ul><p><b>Professional Qualifications
</b></p><ul><li>Works independently in a remote environment and delivers exceptional results during EXL core business hours.
</li><li>Possesses excellent time management and work prioritization skills.
</li><li>Takes ownership of problem solving.
</li><li>Demonstrates excellent written and verbal communication skills, strong analytical skills, and attention to detail.
</li><li>Enthusiastic about Auditing with a desire to work in an environment thriving on teamwork, excellence, collaboration, inclusiveness, and support.
</li></ul><p><b>Salary range $50,000.00-$65,000.00.
</b></p><p>0-10% travel may be required.
</p><p>For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits</p></div>

Assistant Manager - High Cost Drug (HCD) Auditor II

<div><h2 class="jobSectionHeader"><b>Description</b></h2>
<div>
<p>As a Medical Claim Lead Auditor, you will apply your audit, project management and client management skills to lead client audits. You will serve as the team leader and primary interface with administrators. You will review discrepancy issues identified by field auditors, re-adjudicate claims, resolve open issues, and draft the final report. You will contribute to the creation of new tools and approaches.</p>
<p><b>
The Responsibilities</b></p>
<ul>
<li>Conduct pre-implementation and coverage specific audits and accurately document and record all audit findings</li>
<li>Understand client&rsquo;s plans and apprise team of unique provisions/issues prior to audit</li>
<li>Adjust workloads as necessary to achieve successful completion of project</li>
<li>Clearly communicate and professionally interact with vendor and audit team</li>
<li>Review documentation of potential discrepancies for thoroughness and accuracy</li>
<li>Resolve post-audit activities in an accurate and timely fashion</li>
<li>Write quality value-added draft report in a timely manner</li>
<li>Participate in client presentation of findings, when requested</li>
<li>Understand vendors&rsquo; processes, operating environment, and specific challenges and take them into account with daily work</li>
<li>Develop working relationship with vendor counterparts</li>
<li>Distribute individual claim/work queues to team in a timely manner</li>
<li>Efficiently utilize audit-specific analytic techniques, tools and processes</li>
<li>Ensure that Professional Excellence protocols are followed</li>
<li>Meet billable hours target</li>
<li>Seek opportunities to improve work processes and methods in pursuit of quality output and service delivery</li>
<li>Role will be working remotely within the posted locations.</li>
</ul>
<p><b>Qualifications</b></p>
<ul>
<li>5+ years&rsquo; experience in health claims adjudication gained preferably in a consulting environment and/or in a major insurance claims administrator or health plan environment</li>
<li>Solid understanding of health and welfare plan design and all areas of claims administration, as well as of vendors&rsquo; processes and operating environment</li>
<li>Familiarity with all plan types including consumer-driven, PPO, Indemnity and Managed Care</li>
<li>Must demonstrate a high level of claims administration knowledge, including experience with medical, dental, mental health and Medicare</li>
<li>Detailed knowledge of ICD-10 and CPT codes and coding protocols</li>
<li>Must have prior experience in medical claim auditing (e.g., re-evaluating medical claims that were previously processed for adherence to plan design and other program parameters).</li>
<li>Experience auditing both professional and facility claims types.</li>
<li>Must have experience auditing both benefits and pricing.</li>
<li>Excellent oral and written communications skills</li>
<li>Team player with strong work ethic</li>
<li>Self-directed; requiring very little supervision</li>
<li>Previous internal audit experience at a carrier or third-party external audit experience a plus</li>
<li>Bachelor's Degree preferred; High School Diploma required</li></ul><br>
<p></p>
</div>
<h2 class="jobSectionHeader"><b>Qualifications</b></h2>
<div>
<p><b>Compensation and Benefits</b></p>
<p>
Base salary range and benefits information for this position are being included in accordance with requirements of various state/local pay transparency legislation. Please note that base salaries may vary for different individuals in the same role based on several factors, including but not limited to location of the role, individual competencies, education/professional certifications, qualifications/experience, performance in the role and potential for revenue generation.</p>
<p><b>
Compensation</b></p>
<p>
The base salary compensation range being offered for this role is $90,000 to $98,000 USD per year.</p>
<p>
This role is also eligible for an annual short-term incentive bonus.</p>
<p><b>
Company Benefits</b></p>
<p>
WTW provides a competitive benefit package which includes the following (eligibility requirements apply):</p>
<ul>
<li><b>Health and Welfare: </b>Mental health/emotional wellbeing (including Employee Assistance Program), medical (including prescription drug coverage and fertility benefits), dental, vision, Health Savings Account, Commuter Accounts, Health Care and Dependent Care Flexible Spending Accounts, company-paid life insurance, supplemental life insurance, AD&amp;D, group accident, group critical illness, group legal, identity theft protection, wellbeing program, adoption assistance, surrogacy assistance, auto/home insurance, pet insurance, and other work/life resources.</li>
<li><b>Leave Benefits:</b> Paid Holidays, Annual Paid Time Off (includes paid state/local paid leave where required), Short-Term Disability, Long-Term Disability, Other Leaves (e.g., Bereavement, FMLA, ADA, Jury Duty, Military Leave, and Parental and Adoption Leave), <b>Paid Time Off</b></li>
<li><b>Retirement Benefits:</b> Contributory Pension Plan and Savings Plan (401k). All Level 38 and more senior roles may also be eligible for non-qualified Deferred Compensation and Deferred Savings Plans.</li>
</ul>
<p>Pursuant to the San Francisco Fair Chance Ordinance and Los Angeles County Fair Chance Ordinance for Employers, we will consider for employment qualified applicants with arrest and conviction records.</p>
<p>
Note that visa employment-based non-immigrant visa sponsorship and/or assistance is not offered for this specific job opportunity.</p>
<p>
This position will remain posted for a minimum of three business days from the date posted or until sufficient/appropriate candidate slate has been identified.</p>
<p><b>
EOE, including disability/vets</b></p></div></div>

Medical Claim Lead Auditor (Remote)

Rising Medical Solutions

<div>
 <strong>
  Medical Bill Review Auditor (working title: Data Entry Associate)
  <br/>
  <br/>
 </strong>
 Looking to gain professional experience (or transition to the thriving healthcare/insurance industry) while working at a fun and driven company? Are you someone who gets in the "flow" while handling administrative-type work? Rising may have the perfect job for you.
 <br/>
 <br/>
 <em>
  What kind of a person makes a good auditor?
  <br/>
  <br/>
 </em>
 Someone who:
 <br/>
 <br/>
 <ul>
  <li>
   Has meticulous attention to detail
  </li>
  <li>
   Thrives working independently (while still working within the context of a small team)
  </li>
  <li>
   Possesses the ability to be flexible &amp; adaptable
  </li>
  <li>
   Is a good self-manager
  </li>
  <li>
   Likes to stay productive and always have something to do
  </li>
  <li>
   Has an enthusiastic approach to work
  </li>
  <li>
   Is able to work on-site in our Milwaukee office Monday-Friday 8:00am-4:30pm during training until you qualify for working at home
   <br/>
   <br/>
  </li>
 </ul>
 So, what does a "day in the life" of a Medical Bill Review Auditor look like? You will have the opportunity to obtain maximum savings for clients by accurately entering data and reviewing medical bills according to state laws, fee schedules, and other guidelines. Most of your day will include seated computer work performing data entry on workers' compensation-related medical bills. Want to listen to podcasts or music via headphones while you work? Go for it. This position does have production and accuracy performance metrics, so if you are someone who thrives and is motivated by structured individual performance goals, this position may be a good fit.
 <br/>
 <br/>
 Don't have experience in medical billing? No problem- some of our best employees come from retail, food service, and other industries or sectors. What unites us is our commitment to excellence and our entrepreneurial spirit. If this resonates with you, please come join us and help us achieve A Better Way!
 <br/>
 <br/>
 <strong>
  Requirements
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   High School Diploma required, college preferred. Recent graduates are welcome to apply
  </li>
  <li>
   Strong data entry/computer skills required
  </li>
  <li>
   Desire to work in an office environment
  </li>
  <ul>
   <li>
    This position offers a hybrid model after 90-Day introductory period.
   </li>
  </ul>
  <li>
   Certification in a related field (i.e. CPC) a plus
  </li>
  <li>
   Previous medical/health care/insurance industry experience a plus, but not required. Training for this role is paid and provided internally by the company
  </li>
  <li>
   More than 1 job opening with an expected hire date of mid-April.
  </li>
  <li>
   Must live in the Milwaukee, Wisconsin area
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Benefits
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Hourly Rate: $18.00-$20.00
  </li>
  <li>
   Snacks and drinks on Thursday afternoons
  </li>
  <li>
   Ability to work a hybrid schedule of 1 day a week in the office and 4 days at home (after training period)
  </li>
  <li>
   A relaxed, yet upbeat, work environment, with a jeans professional dress code
  </li>
  <li>
   Competitive benefits package, 401k matching, PTO and career growth opportunities (we often promote from within!)
  </li>
  <li>
   Location in Walker's Point (Milwaukee), Free parking
  </li>
  <li>
   Unlimited free coffee!
  </li>
  <li>
   Rising was named a Top Workplace in the healthcare industry for 2023! Check out our profile here: Rising Medical Solutions, Inc Profile (topworkplaces.com)
  </li>
  <li>
   We're on YouTube! Check out our culture at: http://www.youtube.com/user/RisingMedical
  </li>
  <li>
   Want to see more? Check out our:
  </li>
  <ul>
   <li>
    Facebook: https://www.facebook.com/RisingMedicalSolutions
   </li>
   <li>
    LinkedIn: http://www.linkedin.com/company/rising-medical-solutions
   </li>
   <li>
    Glassdoor: http://www.glassdoor.com/Overview/Working-at-Rising-Medical-Solutions- EI_IE322608.11,35.htm pages
   </li>
  </ul>
 </ul>
</div>


Data Entry Associate - Entry-Level Healthcare Office Role - Hybrid

<div>
 <strong>
  Virtual:
 </strong>
 This role enables associates to work virtually full-time, with the exception of required inperson training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
 <br/>
 <br/>
 <ul>
  <li>
   Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
   <br/>
   <br/>
  </li>
 </ul>
 The
 <strong>
  Diagnosis Related Group Clinical Validation Auditor
 </strong>
 is responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims.
 <br/>
 <br/>
 <strong>
  How You Will Make An Impact
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
  </li>
  <li>
   Draws on advanced ICD-10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions.
  </li>
  <li>
   Utilizes audit tools, auditing workflow systems and reference information to generate audit determinations and formulate detailed audit findings letters.
  </li>
  <li>
   Maintains accuracy and quality standards as established by audit management.
  </li>
  <li>
   Identifies potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
  </li>
  <li>
   Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Minimum Requirements
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Requires current, active, unrestricted Registered Nurse license in applicable state(s).
  </li>
  <li>
   Requires a minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement, and a minimum of 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG; or any combination of education and experience, which would provide an equivalent background.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Skills, Capabilities And Experiences
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   One or more of the following certifications are preferred: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC) or Inpatient Coding Credential such as CCS or CIC.
  </li>
  <li>
   Experience with third party DRG Coding and/or Clinical Validation Audits or hospital clinical documentation improvement experience preferred.
  </li>
  <li>
   Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred.
   <br/>
   <br/>
  </li>
 </ul>
 For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $81,852 to $155,088
 <br/>
 <br/>
 Locations:&Acirc; California; Colorado; District of Columbia (Washington, DC), Illinois, New Jersey; Maryland, Minnesota, Nevada; New York; Washington State
 <br/>
 <br/>
 In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company.&Acirc; The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws
 <em>
  .
  <br/>
  <br/>
 </em>
 <ul>
  <li>
   The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
   <br/>
   <br/>
  </li>
 </ul>
 Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
 <br/>
 <br/>
 Who We Are
 <br/>
 <br/>
 Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
 <br/>
 <br/>
 How We Work
 <br/>
 <br/>
 At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
 <br/>
 <br/>
 We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
 <br/>
 <br/>
 Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
 <br/>
 <br/>
 The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
 <br/>
 <br/>
 Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
 <br/>
 <br/>
 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
 <br/>
 <br/>
 Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration (https://info.flclearinghouse.com/) .
</div>


Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)

Trillium Health Resources

<div><div><b>Pay Plan Title: </b>Data Analyst</div><div><b>
Working Title: </b>Senior Claims Specialist</div><div><b>
FLSA Status: </b>Exempt</div><div><b>
Posting Salary Range: </b>$41,102 - $59,518</div><div><b>
Office Location: </b>Remote within North Carolina</div><div></div><div><b><br>
POSTING DETAILS:</b></div><div></div><div><b><br>
Make an Impact</b></div><div></div><div><br>
Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.</div><div></div><div><b><br>
Why Work for Us</b>?</div><div></div><div><br>
Trillium believes that empowering others begins with supporting our team. We offer our employees:</div><div></div><div><br>
<ul><li>
A collaborative, mission-driven work environment</li><li>
Competitive benefits and work-from-home options for most positions</li><li>
Opportunities for professional growth in a diverse inclusive culture</li></ul></div><div></div><div><br>
Every day, our work changes lives &ndash; from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.</div><div></div><div><br>
If you are looking for a unique opportunity to make a tangible impact on the lives of others, apply today!</div><div></div><div><b><br>
What We&rsquo;re Looking For</b></div><div></div><div><br>
Trillium Health Resources has a career opening for a Senior Claims Specialist to join our team! The Senior Claims Specialist performs data analysis, auditing and finalizes adjudication results for claims designated for pre-payment review and post payment review of claim adjudication results through research and knowledge of billing guidelines and policies established by CMS, and NC Medicaid as well as Trillium policies and procedures. This position is also responsible for assisting providers by phone or email with claims processing questions as well as communicating with internal and external stakeholders to facilitate efficient claims resolution.</div><div></div><div><b><br>
On a typical day, you might:</b></div><div></div><div><br>
<ul><li>
Analyze and audit claims adjudication results to determine if claims were accurately submitted and processed according to NC Medicaid guidelines.</li><li>
Analyze and audit claim attachments/medical documentation necessary to appropriately adjudicate a claim.</li><li>
Analyze, audit and take appropriate actions for claims delayed for adjudication due to rejection errors.</li><li>
Identify adjudication errors, provider billing errors, and the need for technical assistance.</li><li>
Ensure the claims system and manual processes are incorporating required actions by reviewing and applying information from departmental trainings, published coverage policies and other NCDHHS documents.</li><li>
Provide training, education and technical assistance to provider agencies based on analysis or audit findings related to basic claim submission guidelines, denial management, system use and updates.</li><li>
Recognize and report suspected system issues or concerns to immediate supervisor for follow-up based on data analysis.</li></ul></div><div></div><div><b><br>
Employee Benefits:</b></div><div></div><div><br>
Trillium knows that work/life balance is essential. That&rsquo;s why we offer:</div><div></div><div><br>
<ul><li>
Typical working hours: 8:30 am &ndash; 5:00 pm; flexible work schedules with some roles with management approval.</li><li>
Work-from-home options available for most positions</li><li>
Health Insurance with no premium for employee coverage</li><li>
Flexible Spending Accounts</li><li>
24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year</li><li>
NC Local Government Retirement Pension (defined-benefit plan) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook</li><li>
401k with 5% employer match and immediate vesting</li><li>
Public Service Loan Forgiveness (PSLF) qualifying employer</li><li>
Quarterly stipend for remote work supplies</li></ul></div><div></div><div><b><br>
Qualifications</b></div><div></div><div><br>
Required:</div><div><ul><li>
High School Diploma/GED and two (2) years of experience in the claims processing or billing or medical coding field; OR</li><li>
Equivalent combination of education/experience.</li><li>
Must have a valid driver&rsquo;s license</li><li>
Must reside within North Carolina</li><li>
Must be able to travel within catchment as required.</li></ul></div><div></div><div><br>
Preferred:</div><div><ul><li>
Associate&rsquo;s degree in Healthcare Administration, Business, or a Human Services field (such as Psychology, Social Work, etc.)</li></ul></div><div><ul><li>
 Hospital claims experience and knowledge</li><li>
 Experience in the areas of physical health claims processing or medical coding</li><li>
 Experience working with Managed Care billing software</li><li>
Certified Professional Coder (CPC), Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS) or similar certification preferred.</li></ul></div><p></p><div><b><br>
Deadline for Application:</b> Open Until Filled</div><div></div><div><b><br>
How to Apply</b></div><div></div><div><br>
To be considered, submit your application and resume through our ADP Career Center. Your resume must include:</div><div></div><div><br>
<ul><li>
Employer name, dates of service (month/year), average hours worked per week, and essential job duties</li><li>
Education details (degree type, date awarded, institution, field of study)</li><li>
Licensure/certification information, if applicable</li></ul></div><div></div><div><br>
After submission, your resume will be reviewed to ensure it meets the essential criteria for the position. You&rsquo;ll be notified by HR regarding your application status as appropriate. All applicants will receive a final update once the recruitment cycle closes.</div><div></div><div><br>
Join our Talent Community through ADP to stay informed about future opportunities. Be sure to keep your resume updated in your profile.</div><div></div><div><b><br>
Trillium Health Resources is an Equal Employment Opportunity (EEO) employer and a drug-free workplace. All candidates must pass a drug test as a condition of employment.</b></div><div></div><div><i><br>
#Innovation #Technology #Careers #NorthCarolina #BehavioralHealth</i></div></div>

Senior Claims Specialist

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