At HCSC, we consider our employees the cornerstone of our business and the foundation to our success. We enable employees to craft their career with curated development plans that set their learning path to a rewarding and fulfilling career.

Come join us and be part of a purpose driven company who is  invested in your future!

Job Summary

This position is responsible for performing Clinical, Billing, Coding, and lowest cost setting reviews for services pre and post payment utilizing Medical, Contractual, Legislative, Policy, and Other Information to validate claims submitted and billed. Conducting research; preparing documentation of findings and consulting with Medical Directors as needed. Coordination with all departments involved in each case required such as Special Investigations, Customer Service, Pass, Network Management, Marketing, Case Management, Medical Review, Legal, Pricing and Database.

Required Job Qualifications:

• Bachelor’s degree; one year of business experience, law enforcement experience, or regulatory agency experience may substitute for each year of college.
• Certified Coding Certification or acquire within 24 months of hire.
• 3 years’ experience in claims processing operations and reporting systems, including 2 years’ experience in auditing, or developing computer system reports.
• Knowledge of accreditation, i.e., URAC, NCQA standards and health insurance legislation.
• Awareness of claims processes and claims processing systems.
• PC proficiency to include Microsoft Word and Excel and health insurance databases.
• Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings.
• Organizational skills and prioritization skills.

Preferred Job Qualifications:

• Registered Nurse (RN) or Licensed Practical Nurse (LPN) with unrestricted license in state.
• 3 years clinical experience

#LI-Hybrid

Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

HCSC Employment Statement:

HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.