Collective Health is hiring a

Claims Specialist

San Francisco, United States

We are looking for a Claims Specialist to be our Auditor and Medical Coding point-person on the Operations Team at Collective Health. The position requires deep knowledge of claims data as well as a passion for applying a systematic approach to improving and maintaining quality. You will perform internal audits of daily claims, work to improve Collective Health’s internal quality program, collaborate with external claims auditors, and provide input on payment integrity work. You will work to improve existing workflows and define new processes as needed. This is an exciting opportunity to take an iterative approach to process design and improvement at a nimble and forward-thinking organization where you will have a direct and lasting impact on claims operations.

 

Responsibilities

  • Perform daily audits across clients and improve internal audit program; including sampling design, identifying trends, and providing inputs into training
  • Collaborate with external auditors to define audit design, provide responses, and ensure final deliverables are correct
  • Participate in the review of medical claims for payment integrity issues (fraud, waste or abuse) and trends associated with billing
  • Contribute new ideas for improving audit workflows and audit queries for accuracy and efficiency
  • Work across operations teams to constantly improve training based on audit findings and new trends in the data
  • Collaborate with engineers on improvements to tooling that will support the audit process

 

Requirements

  • 5+ years of experience and deep knowledge of claims processing, claims auditing, and medical billing/coding experience
  • In depth knowledge of claims processing and coding principles including but not limited to CPT, HCPCS, ICD-10, modifier, and revenue codes, NCCI edits, and APCs
  • Understanding of medical terminology and anatomy. Specific experience in payment integrity is a plus
  • Strong analytical experience including statistical sampling methods, data analysis, and Excel. Knowledge of SQL is a plus
  • Experience with iterative process improvement
  • Strong writing skills, ability to develop presentations, checklists, and review guideline documents
  • Bachelor’s degree

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