Medical Claims Auditor Position Available In Knox, Tennessee

Position Summary The Medical Claims Auditor is responsible for reviewing, analyzing, and auditing medical claims to ensure accuracy, compliance with industry standards, and adherence to summary plan documents. This position will be focused on analyzing claims data to identify claims processing errors. The healthcare auditor should have experience working with medical claims data along with auditing expertise. Essential Duties and Responsibilities The essential functions include, but are not limited to the following: Review and analyze medical claims for accuracy, completeness, and compliance Identify trends and anomalies within claims data and perform root cause analysis Review plan documents, service agreements, and provider contracts Perform site visits (virtual or on site) at Third-Party Administrators to review claim information Apply correct coding guidelines (e.g., ICD-10, CPT, HCPCS) and ensure diagnoses, procedures, and services are properly coded Identify and investigate discrepancies, billing errors, fraud, or abuse, such as duplicate claims, unbundling, upcoding, and incorrect coding Document and communicate audit findings, generate a structured report summarizing results, trends, and recommendations for process improvements Stay current with changes in coding guidelines, insurance regulations, and industry best practices Assist in the development and implementation of quality assurance and compliance programs Communicate with internal and external stakeholders, including customers, insurance carriers, and third-party administrators, to resolve claim-related issues Identify non-routine audit opportunities Perform other duties as assigned Minimum Qualifications (Knowledge, Skills, and Abilities) Bachelor’s degree in healthcare or business-related field preferred 5+ years of experience in healthcare environment – preferably with large payer organizations (TPAs) Big data experience is preferred Ability to work together and collaborate as part of a team Ability to perform all job duties in accordance with HIPAA privacy and security rules as it relates to protected health information Strong judgment, critical thinking skills are necessary Superior written, verbal, and interpersonal communication skills Familiarity with medical terminology and

ICD-10, CPT, HCPCS

Thorough understanding of claims adjudication processes required Location The position is a hybrid remote role with the flexibility to work from home. The incumbent would need to travel to our company headquarters in Knoxville, TN with occasional travel to TPA or client sites as needed. The ideal candidate would be located within driving distance or an easy flight to company headquarters. Benefits Competitive salary Comprehensive health and wellness benefits package Retirement savings plan Opportunities for professional development and advancement Positive and collaborative work environment

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