Claims Auditor - Medicare

Back to Career Site
Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.
What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can live healthy, brighter lives - apply to join our team.
SCOPE OF ROLE
The Claims Auditor is responsible for executing a claim recovery strategy which includes the analysis of claims data for identifying cost containment opportunities both with internal and external partners and auditing processed claims to ensure alignment with contract requirements, proper configuration, and regulatory requirements. This position will coordinate with department leaders and provide staff training when appropriate. The Claims Auditor also assists with the research, resolution, and adjustment of claim inquiries received through appeals, grievances, and other departments.
RESPONSIBILITIES

• Conduct a post-payment review to ensure the appropriateness, accuracy, integrity, and timeliness of processed claims.
• Conduct a Pre-Payment Audit of all high-dollar claims.
• Review and correct claims data errors.
• Research and respond to Claim Escalations from internal and external stakeholders
• Facilitate the research and resolution of claims issues arising from Appeals and Grievances, internal audits, and system configuration.
• Collaborate with internal departments to configure plan benefits and facilitate claim testing.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• High School diploma or GED required; Bachelor's Degree preferred
• Three (3) or more years in healthcare claims, coding, recovery, and/or claim auditing/analytic experience required
• Background in Payment review of claims preferred

PROFESSIONAL COMPETENCIES

• Comprehensive understanding of all aspects of claims processing
• Have a strong understanding of healthcare, medical claim billing standards, recovery practices, operational functions, and company operations.
• Must have strong communication skills (verbal and written)
• Must be highly organized and be able to prioritize work to meet deadlines
• Detail orientated
• Ability to influence and collaborate with business partners throughout the organization.

WORK ENVIRONMENT

• Work responsibilities can be performed in one of Bright's offices, but a remote/work-from-home/virtual experience is also possible with this position.
• Limited travel may be required.

For individuals assigned to a location(s) in California, Bright Health is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant's education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $49,444.55 - $74,166.82 yearly.
Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; up to 21 days of PTO, 10 paid holidays, plus 2 floating holidays per year; and a lifestyle spending account.
We're Making Healthcare Right. Together.
We are realizing a completely different healthcare experience where payors, providers, doctors, and patients can all feel connected, aligned and unified on the same team. By eradicating the frictions of competing needs, we are making it possible to give everyone more of what they want and deserve. We do this by:
Focusing on Consumers We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
Building on Alignment We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.
Powered by Technology
We employ our purpose built, integrated data platform to connect clinical, financial, and social data, to deliver exceptional outcomes.
As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of Bright Health, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.