Medical Needs Processor & Auditor

Location: Austin, TX (Hybrid)

Job Type: Full-time, Non-Exempt

About Us

Crown Administrators is a leading third-party administrator in the healthcare space. Our Company Vision is to radically improve the way individuals interact with the healthcare system. We are committed to providing innovative and efficient health care solutions to our clients, ensuring they receive the best possible care and service. Our team is currently seeking a highly skilled and experienced Medical Needs Processor & Auditor to join our dynamic team.

What We Are Looking For

Our ideal candidate will play a crucial role in managing our Medical Needs environment, optimizing its performance, and driving continuous improvements to support our business goals and enhance our service delivery.

Every Team Member is Driven by a Commitment to Live out These Values:

• Be Authentic: Be true and honest
• Be Helpful: Pitch in and help
• Be Innovative: Seek & embrace innovation
• Be Accountable: Do what you say you are going to

Employees are expected to embrace our core values by being “A Hero in Action.” These values lay the foundation for the way we engage with each other and with our clients. They form the guardrails for our decision making and approach to problem solving.

Position Overview:

We are seeking a meticulous and customer-focused individual to join our team as a Medical Claims Processor & Auditor. This role requires a combination of research acumen, attention to detail, and exceptional customer service skills. As a key member of our organization, you will be responsible for processing medical claims accurately, conducting thorough audits to ensure compliance with regulations and policies, and providing excellent service to our clients and healthcare providers.

Key Responsibilities:

• Review and process medical claims submitted by members or providers promptly and accurately.

• Verify the accuracy and completeness of claim information, including patient demographics, diagnoses, procedures, and billing codes when available.

• Ensure compliance with insurance policies and industry standards.

• Investigate and resolve any discrepancies or issues related to claim submissions.

• Conduct comprehensive medical claims audits to identify errors, discrepancies, or fraudulent activities.

• Analyze claim documentation, including medical records and billing statements, to ensure adherence to coding guidelines and reimbursement policies.

• Research complex medical billing and coding issues to support claims processing and audit activities.

• Interpret coding guidelines, reimbursement policies, and legal requirements to determine appropriate claim adjudication.

• Provide recommendations for improving claims submission procedures and enhancing reimbursement accuracy.

• Serve as members' primary point of contact regarding claims inquiries and resolution.

• Respond promptly to customer inquiries and concerns with professionalism and empathy.

• Collaborate with cross-functional teams to address customer issues and ensure timely resolution.

Skills Required:

• Excellent verbal, written and interpersonal communication skills;

• Must be self-motivator and self-starter;

• Exceptional listening and analytical skills;

• Solid time management skills;

• Ability to multitask and successfully operate in a fast paced, team environment;

• Must adapt well to change and successfully set and adjust priorities as needed;

• Must be proficient with Microsoft Office (intermediate Word, basic Excel)

Qualifications:

• Strong knowledge of medical terminology, ICD and CPT coding, and insurance billing practices.

• Excellent analytical skills with the ability to interpret complex healthcare regulations and guidelines.

• Exceptional attention to detail and accuracy in data entry and documentation.

• Effective verbal and written communication skills with a customer-centric approach.

• Ability to work independently and collaboratively in a fast-paced, deadline-driven environment.

Education/Experience:

• High School Diploma or equivalent
• Proven experience in medical claims processing, auditing, and healthcare reimbursement.

Technical Knowledge:

• SalesForce Experience

• Google Suite Experience

• Claims Management Software experience

What We Offer

• Competitive salary and benefits package
• Dynamic and innovative work environment
• Opportunities for professional growth and development
• Remote work flexibility

Equal Opportunity Statement

We are deeply committed to building a workplace and global community where inclusion is not only valued but prioritized. We are proud to be an equal opportunity employer, seeking to create a welcoming and diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, family status, marital status, sexual orientation, national origin, genetics, neuro diversity, disability, age or veteran status, or any other non-merit based or legally protected grounds. We are committed to providing reasonable accommodation to qualified individuals with disabilities in the employment application process.