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Medical Claims Auditor

Company Overview

Titan Health Management Solutions (Titan) has been in operation since 2002 and began as a boutique firm specializing in zero balance auditing and recovery. Our unique business model and expertise has allowed us to rapidly expand into other markets and other lines of business.

Job Summary

The Reimbursement Auditor is responsible for audit of paid or denied ‘zero balance’ and other assigned hospital medical insurance claims, identification and verification of underpayments, preparation of appeals/grievances to the insurance plan for accurate payment, and assistance with the collection and resolution of their appeals. Reimbursement Auditor serves as subject experts on their assigned plan contracts as well as on coding and reimbursement standards.

Responsibilities and Duties

  • Comprehensive audit of hospital insurance claims payments, including reference to contract payment terms, Medicare and Medicaid coding rules, authorizations, and generally accepted coding and claims payment standards. Audit includes all necessary research to correctly verify claim payment accuracy or denial legitimacy, including telephonic communication with plan where necessary.
  • Analysis of contract language to prospectively identify potential sources of payment error. 

  • Identification and verification of underpayments made to hospital by insurance plan. 

  • Formulation of appeal/grievance reason and argument logic, including accurate calculation of short paid amount

  • Review of denials, partial pays, and payment discrepancies to validate accuracy of initial appeal. Escalate appeals to higher level as appropriate. Includes telephonic/fax/email communication with plan where appropriate. 

  • Audit of paid appeal amounts to verify complete payment. Draft and submit escalated or secondary appeal as required for underpaid accounts. 

  • Assist with collection of appeals, including telephonic communication with plan in cases where that would result in faster or more accurate payment of the appeal.

Qualifications and Skills

  • Detailed working knowledge of Commercial, Medicare and Medicaid claims 

  • Detailed working knowledge of hospital/facility billing and coding rules and guidelines 

  • Professional in both appearance and attitude 

  • Certified Professional Coding (CPC) certification preferred

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