Certified Medical Auditor – Claims Review
Job not on LinkedIn
November 15
📋 Description
• Review provider medical records to validate claim data: Codes billed are accurate, complete, and comply with MSO and payer policies • Codes billed comply with bundling and unbundling guidelines and global period policies • ICD-10 codes are chosen appropriately and to the highest level of specificity • CPT and HCPCS codes accurately report the services rendered including level of E&M code in accordance with AMA, CMS, and state-specific coding standards • Documentation supports billed services under Medicare, Medicaid, and Commercial payer rules • Identify and report potential coding errors, documentation gaps, or billing inconsistencies that impact reimbursement or compliance • Collaborate with nurses, medical director, and claims teams to adjudicate/deny claims with coding and/or documentation errors • Support retrospective and prospective reviews to improve claims accuracy and reduce preventable denials • Participate in internal audits, education sessions, and process improvement initiatives to enhance coding integrity • Stay current on updates to CMS regulations, payer billing policies, and industry coding changes • Protect member and provide confidentiality by adhering to HIPAA and MSO compliance standards
🎯 Requirements
• Current CPC, CCS, or CCA credential from AAPC or AHIMA (required) • Minimum 3 years of professional and facility coding experience, including claim review • Demonstrated knowledge of Medicare, Commercial, and Medicaid coding, billing, and reimbursement requirements • Familiarity with risk adjustment and value-based care models preferred • Proficient with EHR and claims management systems (e.g., Epic, Cerner, IDX, or payer portals) • Strong knowledge of medical terminology, anatomy, physiology, and healthcare regulations • Experience with utilization management, claims auditing, and payment integrity programs • Working knowledge of MCG, InterQual, and CMS National Coverage Determinations (NCDs)/Local Coverage Determinations (LCDs) • Working knowledge of DRG • Prior experience collaborating with provider groups in an MSO or IPA environment
🏖️ Benefits
• 100% employer paid medical, vision, dental, and life coverage • Paid holiday, sick, birthday, and vacation time • 401k matching plan • Additional employee paid coverage options
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