We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.  The Medical Claim Investigator is responsible for reviewing medical paid claims against provider contracts and policies to ensure medical payments have been processed accurately. The Medical Claim Investigator will employ data mining techniques to analyze and audit hospital and physician claims to identify errant claim payments.

KEY RESPONSIBILITIES & JOB FUNCTION:

1. Achieve measured production, quality, and growth results
2. Apply analytics and data mining techniques to client paid claims data
3. Evaluate medical claims for coding and pricing errors using accurate HCPCS, ICD-10, and CPT codes
4. Lookup and review medical claims in payer system to determine methods of payment and validate savings identified
5. Promote a positive team environment that is based around critical thinking and sharing intelligence to help meet both individual and team goals
6. Utilize official coding guidelines and resources as required, including CMS directives and bulletins
7. Comply with HIPAA regulations and Discovery’s HIPAA and Information Security policies and procedures, including required training and incident reporting

Required Skills

1. Knowledge of coding type edits and medical claim reimbursement structures and methodologies
2. Strong computer skills, especially with Microsoft Excel
3. Must be able to prioritize, coordinate, multitask, think outside the box, and be energetic
4. Must be able to work independently while maintaining close attention to detail
5. Ability to read and interpret medical contracts and policies

Required Experience

1. Bachelor’s degree in healthcare or mathematical related area, such as finance, accounting or statistics; or
2. High school diploma or GED with 2+ years of direct experience, such as medical claims investigation, auditing, or data mining
3. Knowledge or experience with medical coding and/or CMS policies and guidelines preferred
4. Knowledge or experience with Coordination of Benefits (COB) is preferred

1. Knowledge of coding type edits and medical claim reimbursement structures and methodologies
2. Strong computer skills, especially with Microsoft Excel
3. Must be able to prioritize, coordinate, multitask, think outside the box, and be energetic
4. Must be able to work independently while maintaining close attention to detail
5. Ability to read and interpret medical contracts and policies