Medical Claims Auditor

🕒 January 31

🤠 Texas – Remote

🤠 Texas – Remote

💵 $30.5k - $42.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Healthcare Insurance • Human Services • Healthcare

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Review medical claims, supporting documentation, and medical records to ensure completeness, accuracy, and compliance with company policies and industry standards • Validate coding accuracy using ICD-10, CPT, and HCPCS guidelines • Interpret and analyze Explanation of Benefits (EOB) and UB-04 claim forms to verify correct billing and payment data • Identify and document discrepancies such as duplicate claims, unbundled services, upcoding, and other billing errors • Communicate audit findings and recommend corrective actions to the claims processing team or management • Apply auditing methodologies and regulatory guidelines (CMS, Medicaid, Medicare, and payer contracts) to ensure claims integrity • Support process improvements to enhance claim accuracy and reduce billing errors

🎯 Requirements

• Minimum of three (3) years of direct medical claims collections experience • Strong knowledge of insurance policy types (HMO, PPO, EPO, Medicare, Medicaid) • Advanced understanding of Explanation of Benefits (EOBs) and medical billing forms UB-04 and HCFA-1500 • Experience navigating payer portals and health information systems (e.g., Availity, Navinet) • Demonstrated ability to perform high-volume outreach and communication

🏖️ Benefits

• Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies