Healthcare (Medical) Claims Auditor – Hybrid

Smart Data Solutions (SDS) is a technology leader in healthcare process automation and interoperability.  We are seeking to add an experienced Claims Auditor to our rapidly growing organization!

A career at SDS is both challenging and rewarding.  With over 500 colleagues across the globe, we’ve created an open and honest culture where we value constant learning and new ideas – no matter what role you’re in at SDS.  We are passionate about our customers’ success and helping our colleagues grow and develop!

What will you be doing?

• Conducting claim, and data capture audits for claims, correspondence, and adjustment audits for one or more clients, in accordance with documented procedure guidelines.
• Researching of medical records to set up and terminate work items and complete manual request for medical records.
• Interpreting and applying policy benefits, following desk level procedures, job aide’s, editing resolutions to assist with processing of urgent claim processing issues.
• Tracking, analyzing, and reporting findings to claim examiners and department leadership.
• Documenting clear and concise audit findings and delivering to corresponding examiners
• Supporting corrective action initiatives to improve BPO operations, SLA’s, and overall accuracy of results/outcomes. Both internal and external to our team.
• Ensuring accurate and timely follow up and follow through of tasks (emails, audit reviews, audit inventory TAT)
• Participating in departmental training and calibration meetings as needed
• Supporting and engaging in client trainings and bi-weekly monthly calibration meetings.
• Establishing and maintaining working relationships in a collaborative team environment
• Sharing new/existing knowledge regarding auditing standards and expectations with others to ensure they can contribute new ideas and solutions to the betterment of the department
• Performing, evaluating, and assisting in defining and improving the quality standards to achieve individual and department performance goals as defined within the department guidelines.
• Practicing interpersonal and active listening to achieve high customer satisfaction and departmental communication standards
• Supporting training and skills development for examining team members.
• Meeting standards for quality and daily production.
• Accurately documenting your time and the number of records processed daily.
• Utilizing verbal and written communication skills and the ability to interact professionally with diverse groups, executives, managers, and subject matter experts (SME).
• Maintaining confidentiality and privacy
• Understanding and complying with your role and responsibilities (audit & test performance expectations, re-prioritization, documentation updates, training, etc..) as established and outlined.
• Utilizing capable of investigative and analytical research skills, demonstrating critical thinking and deductive reasoning
• Challenging the status quo by continuously reviewing personal work processes and questioning traditional or established processes to make improvements
• Performing other duties as assigned.

What are we looking for?

• Minimum: High School Diploma or equivalent
• Experience using current computer equipment and applications such as laptops and Microsoft Office Suite
• Proficiency with Ten Key and Typing skills.
• Ability to read and interpret Standard Operating Procedure documents and performance / production reporting.
• Intermediate level experience with MS Excel
• Basic anatomy and medical terminology knowledge
• 3 year(s) of experience in Health Care claim operations and/or Quality Assurance and Audit function
• Knowledge of medical claim forms HCFA, CMS1500, UB04 and ADA
• Knowledge and experience with Medical Code sets ICD 10, HCPCS, CPT and Modifiers, value codes, type of bill, condition codes etc.
• Conceptual knowledge of coordination of benefits, member/provider claim appeals, government programs (Medicare/Medicaid)

Preferred candidates possess:

• Practical Claim Auditing experience on applicable client platforms
• Organizational skills and experience prioritizing project work and tasks
• Experience in the health care industry working with medical insurance large Health Plan or Third-Party Administrator.
• Medical billing & Coding
• Certified Coding credentials (AHIP or AAPC)
• Documenting audit workflow and creating quality statistics reporting

Why this is the company for you?

• A company culture that is authentic and values teamwork, humility, and fairness! We work hard for our customers and have fun along the way!
• A professional development and growth-oriented workplace
• Generous benefits including, health, dental, vision and disability insurance
• 401(k) with a company match to provide a better future in your retirement years
• Work-life balance with competitive paid time off package; including vacation, holidays, and a floating day

Who is Smart Data Solutions?

For over 20 years, Smart Data Solutions has been partnering with leading payer organizations to provide automation and technology solutions enabling data standardization and workflow automation. The company brings a comprehensive set of turn-key services to handle all claims and claims-related information regardless of format (paper, fax, electronic), digitizing and normalizing for seamless use by payer clients. Solutions include intelligent data capture, conversion and digitization, mailroom management, comprehensive clearinghouse services and proprietary workflow offerings. SDS’ headquarters are just outside of St. Paul, MN and leverages dedicated onshore and offshore resources as part of its service delivery model. The company counts over 420 healthcare organizations as clients, including multiple Blue Cross Blue Shield state plans, large regional health plans and leading independent TPAs, handling over 500 million transactions of varying types annually with a 98%+ customer retention rate. SDS has also invested meaningfully in automation and machine learning capabilities across its tech-enabled processes to drive scalability and greater internal operating efficiency while also improving client results.

SDS recently partnered with a leading growth-oriented investment firm, Parthenon Capital, to further accelerate expansion and product innovation.

Location: Smart Data Solutions is headquartered in Eagan, MN.  This position has been approved for our Minnesota in-office/hybrid work schedule.

Smart Data Solutions is an equal opportunity employer.

All qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, age, marital status, pregnancy, genetic information, or other legally protected status

Due to access to Protected Healthcare Information, employees in this role must be free of felony convictions on a background check report.