|Skills:||Auditing,Evaluation and Management Coding,Utilization Management,Medical Claims processing
|Specialties:||OHP and CMS Benefits
|Required Certifications:||AAPC or AHIMA
|Required Experience:||1 to 2 years
|Preferred Experience:||5 to 7 years
|Location:||Portland, OR* Note: This listing is for a remote position
Are you excited to step into a complex world that
requires a blend of mind, heart and flexibility? We at CareOregon have been
strengthening communities since 1994 by making health care work for everyone.
As a nonprofit health plan largely focused on Oregon's Medicaid population, we
find fulfillment in supporting the underserved.
General Statement of Duties
As a member of the Claims Payment Integrity Team, the
Medical Record Claims Auditor is responsible for performing medical record and
claims review/audits for Medicare, Medicaid and/or other claims data. This
includes pre-payment and post-payment reviews to ensure that proper medical
coding guidelines have been followed for claim payment accuracy.
Essential Position Functions
internal reviews/audits of medical records and healthcare claims.
medical records to ensure they are complete, accurate and compliant with
State/Federal regulations and CareOregon policies.
publish and submit detailed reports on audit findings to Cost/Contracting,
Utilization and Payment Integrity Decision-makers (CUPID) for approval on
post-payment reviews and repayment/recovery process.
investigation/audit finding letters to healthcare providers, and respond
to provider questions pertaining to the audit findings.
claims data to identify trends with potential overpayments,
overutilization, fraud, waste and abuse (FWA) and develop reports to
support Claims Payment Integrity initiatives and track recoveries/savings.
knowledge of healthcare coding conventions to identify suspicious patterns
in medical record documentation.
identify and resolve claims issues and determine root causes.
and enhance documentation and training materials in conjunction with
Claims Trainer for claims payment initiatives impacting claim processing
and correctly adjudicate medical, dental and mental health claims and/or
re-adjudicate or adjust/correct claims including some complex and
difficult claims, in accordance and/or compliance with plan provisions,
State/Federal regulations and CareOregon policies/procedures.
and process repayment/recovery refunds which may result in posting refunds
and claim adjustments or re-adjudication.
Education and/or Experience
unencumbered license as a registered nurse in the State of Oregon
of Science in Nursing
- AAPC or
2 years’ auditing experience and advanced experience in Evaluation and
Management coding or medical claims processing in the health insurance
1 year healthcare experience that demonstrates expertise in conducting
utilization management (UM)
5 years’ clinical experience in primary care and/or specialty clinic
may be given to qualified candidates who have UM experience administering
the Oregon Health Plan (OHP) and the Centers for Medicare and Medicaid
Services (CMS) (Medicare) benefits
Work Location: Potential
to work from home
Equal opportunity employer. This
company considers all candidates regardless of race, color, religion, sex,
sexual orientation, gender identity, national origin, disability or veteran
Veterans welcome to apply