Healthcare (Medical) Claims Auditor

Smart Data Solutions (SDS) is a technology leader in healthcare process automation and interoperability.  We are seeking to add an experienced Claims Auditor to our rapidly growing organization!   

A career at SDS is both challenging and rewarding.  With over 500 colleagues across the globe, we've created an open and honest culture where we value constant learning and new ideas - no matter what role you're in at SDS.  We are passionate about our customers’ success and helping our colleagues grow and develop! 

What will you be doing?

Smart Data Solutions Claims Auditors perform quality audits for all aspects of the work performed by our claim examiners on behalf of our client including, but not limited to claim edit resolution, correspondence/adjustments, medical review, and data capture to ensure that work performed for our client is complete, accurate, and in alignment with service level agreements.

Claims Auditors at SDS…

• Process claim inventory in support of ramp up/ramp down and inventory reduction plans, ensuring that all productivity, quality, and timeliness goals are achieved based on established standards.
• Research of medical records to set up and terminate work items and complete manual request for medical records.
• Interpret and apply policy benefits, able to follow desk level procedures, job aids, edit resolutions to assist with processing of urgent claim processing issues.
• Track, analyze, and report findings to claim examiners and department leadership.
• Document clear and concise audit findings and deliver to corresponding examiners
• Support corrective action initiatives to improve BPO operations, SLA’s, and overall accuracy of results/outcomes. Both internal and external to our team.
• Ensure accurate and timely follow up and follow through of tasks (emails, audit reviews, audit inventory TAT)
• Participate in departmental training and calibration meetings as needed
• Support and engage in client trainings and bi-weekly monthly calibration meetings.
• Establish and maintain working relationships in a collaborative team environment
• Share new/existing knowledge regarding claim resolutions and process with others to ensure they understand can contribute new
• ideas and solutions to the betterment of the department.
• Practice interpersonal and active listening to achieve high customer satisfaction and departmental communication standards.
• Support training and skills development for examining team members.
• Meet standards for quality and daily production.
• Accurately document your time and the number of records processed daily.
• Verbal and written communication skills and the ability to interact professionally with diverse groups, executives, managers, and subject matter experts (SME).
• Maintain confidentiality and privacy
• Understand and comply with your role and responsibilities (audit & test performance expectations, re-prioritization, documentation updates, training, etc..) as established and outlined.
• Capable of investigative and analytical research, demonstrating critical thinking and deductive reasoning
• Challenge the status quo by continuously reviewing personal work processes and questioning traditional or established processes to make improvements
• Perform other duties as assigned.

What are we looking for?

• Minimum: High School Diploma or equivalent
• Experience using current computer equipment and applications such as laptops and Microsoft Office Suite
• Proficiency with Ten Key and Typing skills.
• Ability to read and interpret Standard Operating Procedure documents
• Intermediate level experience with MS Excel
• 3 year(s) of experience in Health Care claim operations
• Knowledge of medical claim forms HCFA, CMS1500, UB04 and ADA
• Knowledge and experience with Medical Code sets ICD 10, HCPCS, CPT and Modifiers, value codes, type of bill, condition codes etc.
• Conceptual knowledge of coordination of benefits, member/provider claim appeals, government programs (Medicare/Medicaid)
• Preferred candidates possess:
• Organizational skills and experience prioritizing project work and other tasks
• Experience in the health care industry working with medical insurance large Health Plan or Third-Party Administrator

Why this is the company for you?

• A company culture that is authentic and values teamwork, humility, and fairness! We work hard for our customers and have fun along the way!
• A professional development and growth-oriented workplace
• Generous benefits including, health, dental, vision and disability insurance
• 401(k) with a company match to provide a better future in your retirement years
• Work-life balance with c