Let’s do great things, together
Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.
We are seeking a Hospital Claims Auditor to join our team. This position provides clinical and technical analysis for interpretation of appropriate procedural and diagnostic coding and payment of hospital inpatient claims and related inputs; determines whether facilities are in compliance with industry billing standards.
1. Identifies billing irregularities on hospital bills and recommends next level of review, including telephonic discussions with hospital, referral to vendor, or on site audit at hospital. Recommends solutions to resolve billing inconsistencies.
2. Communicates claim payment decisions to processing staff and recommends and coordinates processes to review large dollar hospital claims. Enhances and problem solves new or inconsistent claim payment and coding policies.
3. Determines, with use of decision tree, need for claims to be adjudicated with no further review, review records or facilitates an on site audit at hospital. Develops and documents hospital claims review and audit policies.
4. Provides advice and recommendations to benefit programming unit on proper system coding and editing related to benefits ensuring accurate claims payment.
5. Collaborates with other Moda areas to provide clinical policy representation at meetings to ensure that decisions, which affect claim processing, are appropriate and will result in cost effective, efficient and accurate claims payment.
6. Reviews provider and member complaints and appeals to determine trends and recommend changes for continuous improvement edits related to coding. Assists Healthcare Services with written responses to inquiries.
7. Tracks reporting statistics and data and compile meaningful and appropriate reports.
8. Monitors contracted vendors that provide services to control claims expense through negotiation, audits, clinical editing, etc.
9. Assists Healthcare Services in review of appealed claims requiring interpretation of clinical and pricing documentation (including, but not limited to: operative reports, office notes, system data).
10. Investigates provider aberrant/fraudulent billing practices utilizing paid claim data and review of medical records.
11. Communicates with vendors, providers, and members through written correspondence. In addition, handles phone inquiries regarding correct coding and/or clinical editing when call requires coding and clinical editing expertise and understanding of the medical records.
12. Provides education to employees and provider offices as needed to facilitate an understanding of correct claim coding, use of CPT, ICD9, ICD-10 HCPCS, etc.
13. Performs other related duties and projects as assigned.
Are you ready to be a betterist?
If you’re ready to make a difference that matters, we want to hear from you. Because it’s time to discover what’s possible.
Together, we can be more. We can be better.
Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law.