Medical Claims Investigator

Why This Role Matters

• As a Claims Auditor, you will play an important role in ensuring the accuracy and integrity of healthcare claim payments. By leveraging data analysis, auditing expertise, and coordination of benefits methodologies, you will help identify payment discrepancies, coding issues, and savings opportunities that directly benefit our clients and business.
• Your work contributes to improved financial outcomes, regulatory compliance, and operational excellence by validating medical claim payments and ensuring adherence to provider contracts, reimbursement methodologies, and industry guidelines. Working closely with internal teams, you will help uncover actionable insights that drive value while supporting accurate and compliant claims processing.
• This is an exciting opportunity for someone who enjoys solving complex problems, analyzing healthcare data, and applying coding and reimbursement expertise to make a measurable impact in a fast-paced environment.

What You'll Do

In this role, you will have the opportunity to:

• Analyze paid medical claims using data mining and coordination of benefits techniques to identify payment errors and recovery opportunities.
• Audit hospital and physician claims to validate payment accuracy and ensure compliance with provider contracts and reimbursement methodologies.
• Evaluate claims using HCPCS, ICD-10, and CPT coding standards to identify coding, billing, and pricing discrepancies.
• Research claim payment activity within payer systems to determine payment methodologies and validate identified savings opportunities.
• Apply coding guidelines, CMS directives, regulatory requirements, and industry resources to support accurate claims review and auditing practices.
• Collaborate with teammates and cross-functional partners to share insights, resolve issues, and contribute to team performance goals.
• Maintain compliance with HIPAA requirements and organizational policies while handling sensitive healthcare information.
• Contribute to production, quality, and growth objectives through accurate analysis, critical thinking, and continuous process improvement.

What You Will Bring

Required Qualifications

• High school diploma or GED.
• Two (2) or more years of experience in medical claims investigation, data mining, coordination of benefits auditing, claims auditing, or a related healthcare payment integrity function.
• Knowledge of medical claim reimbursement structures, methodologies, and coding edit practices.
• Proficiency in medical terminology, medical procedures, diagnoses, treatments, and healthcare billing concepts.
• Experience applying coding guidelines and federal and state regulations related to healthcare coding and billing.
• Knowledge of Medicare, Medicaid, and other healthcare reimbursement programs.
• Familiarity with automated claims payment systems and/or payer platforms such as Facets, QNXT, or similar systems.
• Advanced Microsoft Excel and computer skills.
• Strong analytical, organizational, problem-solving, and critical-thinking abilities.
• Ability to prioritize multiple assignments, work independently, and maintain exceptional attention to detail.

Preferred Qualifications

• Bachelor's degree in Healthcare Administration, Health Information Management, Business, or a related field.
• Medical billing and coding certification (e.g., CPC, CCS, or equivalent).
• Additional experience in healthcare claims auditing, payment integrity, or reimbursement operations.
• Experience working with large healthcare datasets and conducting detailed claims analysis.
• Knowledge of commercial, government, and managed care reimbursement methodologies.
• Professional licensure, certification, or board certification relevant to healthcare coding, auditing, or reimbursement.

Compensation

The salary range for this position is $50,000-$55,000.

Actual compensation is based on experience, skills, education, work location, and internal equity. This position may also be eligible for incentive compensation and the comprehensive benefits outlined in the My Total Value section. Benefits include health insurance, a 401(k) program, and bonus opportunities.

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Why Claritev?

Healthcare is complex. We help make it clearer.

At Claritev, you'll do work that matters. Together, we're helping make healthcare more transparent and affordable for all through the power of data, technology, and expertise. We offer meaningful opportunities to grow your career, collaborate with talented colleagues, and make an impact on the clients and communities we serve. If you're looking for purpose, growth, and a team that succeeds together, you'll find it here.

What Guides Us

At Claritev, innovation, agility, and a focus on results drive our success. We embrace bold thinking, work as one team, take ownership, and strive for excellence in everything we do - creating meaningful impact for our clients, communities, and each other.