Job Title: Auditor Medical Review & Pended Claims
Work Schedule: Monday Friday, 9:00 AM to 5:00 PM
Telework Eligible: Yes
Position Overview: Penda Aiken Inc. is a staffing firm located in Brooklyn, New York. Our client is a New York State Agency and is seeking is seeking a detail-oriented Auditor to join our Bureau of Medical Review within the Pended Claims unit for a State Department of Health office. This role is responsible for reviewing and adjudicating medical claims according to established policies, assisting healthcare providers with billing processes, and performing essential administrative and database tracking functions.
Department & Division Purpose: Our state health agency works to optimize healthcare delivery and manage state healthcare programs by wisely allocating available resources. The Division of Medical and Dental Directors supports policy direction across managed care, fee-for-service, and waiver programs. The Bureau of Medical Review oversees operational functions, including prior authorizations and the review of claims that pend for pricing, medical necessity, timeliness, and adherence to state submission policies.
Key Responsibilities:
Claims Review & Processing: Review medical claims according to written guidelines and procedures; escalate complex claims and unresolved issues to appropriate senior staff.
Provider Support & Education: Answer incoming telephone calls, transfer calls to appropriate staff, and educate healthcare providers on billing processes and resource navigation.
Data Management & Tracking: Maintain internal databases for tracking purposes; perform accurate data entry across multiple databases.
Administrative Operations: Monitor incoming emails in a shared mailbox and route to appropriate personnel; date-stamp, file, fax, scan, copy, and archive documents.
Special Projects: Assist with special projects and perform additional operational tasks as assigned.
Professional Standards: Maintain strict confidentiality, professional demeanor, and positive communication at all times.
Qualifications & Requirements:
Education: High School Diploma or equivalent required.
Technical Skills: Proficiency with Microsoft Word and Excel, standard office equipment, and database navigation.
Soft Skills: Strong flexibility, innovative problem-solving, team-oriented mindset, and professional verbal communication.
Preferred Experience: Previous medical claims, billing, or audit experience preferred, but not required.