Medical Record Auditor & Claims Support
Public Consulting Group

Job Info

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Job Description

 

SUMMARY OF FUNCTIONS
The Claims Representative and Medical Record Auditor supports the entire claim process and performs medical record audits for all implemented agencies. Ensures accurate reporting of claims processed, internal denial research results, and final remittance advice processing including discussion with internal management, clients, and/or public agencies to ensure understanding of results. Ensures accurate reporting of medical record audits including discussion with internal management, clients, and/or public agencies to ensure understanding of results.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES (100%)
• Quickly and effectively researches medical record audits using the internal applications and support documentation to determine compliance with agency specific requirements. Completes the audit results sheet and summaries as necessary or required by the contract. (60%)
• Quickly and effectively researches denied claims to determine root cause of denial and solutions for correction by either the agency or internal fixes to the claiming application or validation routines. (10%)
• Reviews claim files (837s) and remittance advice (835s) for accuracy and completeness. Calls or emails client, agency or other necessary individuals to secure and/or update incorrect or missing information. (10%)
• Reviews all reference files needed by each agency for appropriate claim validation for accuracy and completeness. Calls or emails client, agency or other necessary individuals to secure and/or update incorrect or missing information. (10%)
• Maintains and reviews all internal and external log sheets for accuracy and ensures all data is current and posted timely. (10%)

 

ORGANIZATIONAL RELATIONSHIPS
Reports directly to the ASO Claims Director

 

QUALIFICATIONS AND EDUCATION REQUIREMENTS
• Claiming or coding certification desired, preferably with a nationally recognized certify organization, either AAPC (American Academy of Professional Coders) and/or AHIMA (American Health Information Management Association).
• Understands federal, state, and local claiming requirements and guidance, especially Medicare and Medicaid.
• Must understand coding guidance, including CPT (Current Procedural Terminology), HCPCS (Healthcare Common Procedural Coding System), and ICD-10-CM (Internal Classification of Diseases, 10th Edition, Clinical Modification) as it effects the client and/or agency.
• Extensive experience in the full claim process particularly regarding Medicaid requirements.
• Excellent oral and written communication are required.
• Experience with MS-Office (especially Word and Excel).

 

PREFERRED SKILLS
• Must understand claims processing and be able to read, review, and analyze claim data files (837s) and claim remittance advice (835s) for errors.
• Must understand denial codes, their root cause, and how they are corrected.
• Must be able to review medical record documents using federal, state, and local guidelines, disseminating the results and the information used to reach the decision in a clear and concise manner.
• Must be able to articulate and disseminate information to all parties internal and external in a manner that enhances understanding and reduces further errors.
• Must be able to meet contractual deadlines, often multiple deliverables with a short turn-around requirement.
• Must be able to manage and complete multiple project tasks, often daily.

QUALIFICATIONS AND EDUCATION REQUIREMENTS
• Claiming or coding certification desired, preferably with a nationally recognized certify organization, either AAPC (American Academy of Professional Coders) and/or AHIMA (American Health Information Management Association).
• Understands federal, state, and local claiming requirements and guidance, especially Medicare and Medicaid.
• Must understand coding guidance, including CPT (Current Procedural Terminology), HCPCS (Healthcare Common Procedural Coding System), and ICD-10-CM (Internal Classification of Diseases, 10th Edition, Clinical Modification) as it effects the client and/or agency.
• Extensive experience in the full claim process particularly regarding Medicaid requirements.
• Excellent oral and written communication are required.
• Experience with MS-Office (especially Word and Excel).
• Preferred candidate will have 5+ years of experience with significant claims processing and medical record auditing.
• Must be able to manage clients, both internal and external directly and fairly.
• Must be able to manage time independently to ensure that deliverables and tasks meet contractual obligations of delivery dates.

This job has expired.