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Medical Claims Reviewer at CNSI in Lansing, Michigan

Posted in Other 30+ days ago.

Type: Full Time

Job Description:


The role of the Medical Claims Reviewer is to provide advanced guidance and to work closely with team members and clients with respect to billing and documentation policies, procedures, regulations, and requests for clarification for inconsistent, debatable, or non-specific documentation. This role is a member of the Medical Claims Review team and reports directly to the Medical Claims Reviewer, Manager or Director.

What you will do:

* Function as an individual contributor and work independent of supervision and exercises extensive latitude for independent judgement.
* Review charts, records and documentation for compliance with federal and state coding regulations, guidelines, and policy to ensure that charts and documentation match with supporting evidence of items that are billed on claims forms for submission of payment.
* Adjudicate claims while ensuring that all regulations are met in a timely manner.
* Assist with reviewing claims prior to payment, resulting in initial determinations.
* Assist with audits of records to identify irregularities or fraud by providers.
* Assist to ensure that billing is conducted in accordance with Current Procedural Terminology (CPT) guidelines.
* Assist in the review of billing of services that were not provided, misrepresentations of services provided, and compliance with policies and procedures.
* Ensure optimal reimbursement while adhering to federal and state regulations and Medicaid policies.
* Assist with working with Provider Support on resolution of provider issues.
* Assist in reviewing, researching, investigating, and replying to inquiries concerning compliance, inappropriate coding, denials, and billable services.

Who You Are:

* You have a Bachelor's Degree with 12+ years of relevant work experience.
* You are currently a Certified Professional Coder (CPC) or COC, CIC, CPMA Certification from AAPC or AHIMA (or willing to take the test within 6 months of employment).
* You have an understanding CHAMPS, Medicaid.
* You have knowledge of auditing concepts and principles.
* You have expert technical knowledge of statutory regulations and medical terminology.
* If you are a registered nurse, it would be "a plus".
* If you have experience in medical coding and billing procedures, it would be "a plus".
* If you understand Electronic Health Records, it would be "a plus".
* If you have a Microsoft background (Word, Excel), it would be "a plus".
* If you have knowledge of statutory regulations and medical terminology, it would be "a plus".

About Us:

We are proud to be a partner to the public sector, a trail blazer in health IT and a passionate advocate for better health, better care and lower costs for millions of Americans. Innovation is core to our DNA and through our iCare program we invest in the well-being of our employees and the communities in which we live and work. You will be offered a solid compensation package which includes:

* Annual and Other Paid Leave
* Medical/Dental Insurance
* Flexible Spending Account (FSA) Plan
* Disability Insurance (Short & Long Term)
* Life Insurance
* 401(k) Retirement Savings Plan
* Employee Assistance Program
* College Savings Plan
* Tuition & Training Assistance
* Paid Holidays
* Employee Referral Program

CNSI maintains a policy supporting equal employment opportunity. Employment decisions at CNSI are made without regard for race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, marital status, genetic status, family responsibilities, protected veteran status or any other status protected by applicable Federal, state, or local law. We are proud of our diversity and encourage all qualified applicants to apply. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor s legal duty to furnish information. 41 CFR 60-1.35(c)