Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Working under general supervision, audits complex outpatient, inpatient and professional claim irregularities, overpayments and provider appeals from a clinical coding perspective, applying coding guidelines. Analyzes provider billing for abnormalities, questionable billing practices and proper coding combinations from a clinical and coding perspective and documents denial reasoning or erroneous activity.

This position has the option to work remotely; Ohio residents preferred. Seeking applicants with RN experience, DRG, and/or hospital bill auditing experience.

Responsibilities

Clinical Auditor

• Audits outpatient, inpatient and professional claims from a clinical and coding perspective applying coding guidelines and edits. Assesses for inappropriate billing combinations, inherent charges, provider supporting documentation, etc.

• Documents audit results including denial reasons, erroneous activities, etc. and updates systems accordingly.

• Maintains knowledge in coding and billing guidelines and trends.

• Reviews provider appeals applying coding guidelines or edits.

• Identifies edits to adjudication system that are not working properly or need to be installed so claims can be processed. Works with more senior levels to implement changes.

• Interacts with internal or external auditors or vendors on claim coding updates, procedure changes, etc.

• Discusses consult findings with Physician Reviewers and reviews edit updates and questions with payment recovery staff.

• Performs other duties as assigned.

Sr Clinical Auditor

• Audits outpatient, inpatient and professional claims from a clinical and coding perspective applying coding guidelines and edits. Assesses for inappropriate billing combinations, inherent charges, provider supporting documentation, etc.

• Documents audit results including denial reasons, erroneous activities, etc. and updates systems accordingly.

• Identifies additional opportunities for recovery and avoidance. Researches opportunities to better control medical spending and presents ideas to management.

• Researches and maintains knowledge in coding and billing guidelines and trends. Participates in implementation of new or updated policies and processes.

• Reviews provider appeals applying coding guidelines or edits.

• Identifies edits to adjudication system that are not working properly or need to be installed so claims can be processed. Works with lead or manager to implement changes.

• Orients, trains, assists and reviews work of more junior level staff.

• Interacts with internal or external auditors or vendors on claim coding updates, procedure changes, etc.

• Discusses consult findings with Physician Reviewers and reviews edit updates and questions with payment recovery staff.

• Performs other duties as assigned.

Qualifications

Clinical Auditor & Sr. Clinical Auditor

Education and Experience

• Graduate of a registered nursing program approved by the Ohio State Nursing Board.Bachelor’s Degree preferred.

• In lieu of RN, Bachelor of Science in medical related field.

• 3 years as a Clinical Auditor or equivalent combination of clinicaland medical auditing experience.

Professional Certification(s)

• Certified Medical Auditor (if not certified required to obtain within 18 months of hire).

• Certified Coder preferred.

Technical Skills and Knowledge

• Knowledge of ICD codes.

• Knowledge of procedure codes.

• Knowledge of Revenue Codes, HCPC Codes and CPT codes.

• Knowledge of industry standard billing rules and regulations for professional claims billing, outpatient claims billing and inpatient claims billing.

• Knowledge of insurance regulations.

• Knowledge of coding and auditing techniques.

• Good written communication skills.

• Intermediate Microsoft Office and claims adjudications systems skills.

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

A Great Place to Work:

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.

• Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.

• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.

• Discounts at many places in and around town, just for being a Medical Mutual team member.

• The opportunity to earn cash rewards for shopping with our customers.

• Business casual attire, including jeans.

Excellent Benefits and Compensation:

• Employee bonus program.

• 401(k) with company match up to 4% and an additional company contribution.

• Health Savings Account with a company matching contribution.

• Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.

• Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.

• Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.

• After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:

• Career development programs and classes.

• Mentoring and coaching to help you advance in your career.

• Tuition reimbursement up to $5,250 per year, the IRS maximum.

• Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual:

Medical Mutual’s status as a mutual company means we are owned by our policyholders, not stockholders, so we don’t answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There’s a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We’re not just one of the largest health insurance companies based in Ohio, we’re also the longest running. Founded in 1934, we’re proud of our rich history with the communities where we live and work.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.

Title: Clinical Auditor

Location: Ohio

Requisition ID: 2400330