Senior Claims Processor, Auditor

• Review and process medical claims submitted by members or providers promptly and accurately
• Verify the accuracy and completeness of patient demographics, diagnoses, procedures, and billing codes when available
• Ensure compliance with insurance policies and industry standards
• Investigate and resolve discrepancies or issues related to claims submissions
• Conduct comprehensive medical claims audits to identify errors, discrepancies, or fraudulent activities
• Analyze claims documentation, including medical records and billing statements, for adherence to coding guidelines and reimbursement policies
• Research complex medical billing and coding issues
• Interpret coding guidelines, reimbursement policies, and legal requirements for claims adjudication
• Recommend improvements to claims submission procedures and reimbursement accuracy
• Serve as members’ primary point of contact for claims inquiries and resolution
• Respond to customer inquiries and concerns professionally and empathetically
• Collaborate with cross-functional teams to address customer issues and ensure timely resolution

• Must be located in the Austin, TX area; occasional travel to office required
• High School Diploma or equivalent
• Proven experience in medical claims processing, auditing, and healthcare reimbursement
• Strong knowledge of medical terminology, medical coding, and insurance billing practices
• Excellent analytical skills with the ability to interpret complex healthcare regulations and guidelines
• Exceptional attention to detail and accuracy in data entry and documentation
• Effective verbal and written communication skills with a customer-centric approach
• Ability to work independently and collaboratively in a fast-paced, deadline-driven environment
• Must be self-motivator and self-starter
• Exceptional listening and analytical skills
• Solid time management skills
• Ability to multitask and successfully operate in a fast paced, team environment
• Must adapt well to change and successfully set and adjust priorities as needed
• Salesforce experience
• Google Suite experience
• Claims management software experience

Demonstrates expertise in medical claims processing, auditing, and healthcare reimbursement, with strong knowledge of medical terminology, coding guidelines, and insurance billing practices. Excels in analytical skills, attention to detail, and effective communication to resolve claims inquiries and ensure compliance with industry standards.

• Medical Claims Processing
• Medical Coding
• Healthcare Reimbursement
• Claims Auditing
• Salesforce Experience

• Medical Terminology
• Insurance Billing Practices
• Claims Documentation Analysis
• Coding Guidelines Interpretation
• Data Entry Accuracy

• Analytical Skills
• Effective Communication
• Attention to Detail
• Time Management
• Customer-Centric Approach

• Compliance
• Healthcare Regulations
• Reimbursement Policies
• Claims Inquiries
• Discrepancy Resolution

• Claims Management Software
• Google Suite