Medical Claims Auditor

Job not on LinkedIn

October 16

🤠 Texas – Remote

Although this job is listed in Texas, this company may be open to hiring remote in other states.

💵 $30.5k - $42.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

🦅 H1B Visa Sponsor

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Gainwell Technologies

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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.

10,000+ employees

⚕️ Healthcare Insurance

💰 Grant on 2023-06

📋 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 3 years of experience handling appeal claims in a hospital or healthcare setting. • Ability to interpret EOBs and UB-04 claim forms required. • Working knowledge of ICD-10, CPT, HCPCS, DSM-IV, and CMS-1500 forms preferred. • Certification in medical coding (CPC, CCS, or equivalent) strongly preferred. • Strong analytical and problem-solving skills with high attention to detail. • Proficiency in Microsoft Office applications, particularly Excel and Word. • Excellent communication skills and ability to work effectively in a remote environment.

🏖️ Benefits

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