Hospital Bill Audit Eligibility and Research Associate

Optum Insight seeks a Hospital Bill Audit Eligibility and Research Associate to support the Post-Pay Eligibility & Research group within the Hospital Bill Audit team. This role involves pre-audit and post-audit analysis and research of claims and client contract information to determine eligibility of claims for Hospital Bill Audits and overpayment calculations.

The position is full-time, Monday to Friday, with flexible 8-hour shifts between 8:00 am - 5:00 pm local time and occasional overtime. Four weeks of paid on-the-job training are provided.

Primary responsibilities include:

• Reviewing and analyzing claims using payer claim systems to verify eligibility for audits.
• Examining contracts between clients and providers to identify payment methodologies, exclusions, and non-covered charges.
• Determining overpayment calculations and refunds due.
• Documenting payment analysis and research outcomes and approving or rejecting claims.
• Completing annual compliance training and maintaining client system access.
• Responding to operational inquiries and providing feedback on ineligible claims.

Candidates must have at least 1 year of experience in medical claims processing, billing, collections, or contract analysis and a high school diploma or GED. Understanding payment methodologies (percent of charge, stop loss, DRG, per diem, case rate) and HIPAA regulations is required. Proficiency with Microsoft Office is essential.

Remote work is permitted within Mainland USA with requirements for a dedicated work area and secure handling of sensitive documents. A reliable high-speed internet connection is necessary.

Soft skills needed include strong attention to detail, problem-solving, math and communication skills, and the ability to prioritize work and learn complex evaluations.