Remote Medical Claims Processor Auditor
- Description:
- Conduct routine monitoring and audits of procedures, including but not limited to billing systems audits, Encounter submission audits, and client audits.
- Understand and stay current with client contract criteria and requirements ensuring client services are compliant as well as meet client expectations.
- Generate and submit all required Commercial claims reporting.
- Play a vital role in preparing for the annual Health Plan audits.
- Confirm pricing is correct in the fee tables after the downloads are complete.
- Monitor internal and external processes to detect any practices that, either directly or indirectly, result in fraud, abuse or waste that results in unnecessary costs.
- Participate in auditing and submitting appeals and UM Challenges for Reinsurance process.
- Run access queries and impact reports as needed for administrative purposes.
- Assist coworkers and Internal Auditors in additional compliance and auditing responsibilities, including pre-payment and post-payment audits.
- Consistently exercise independent judgment and discretion in matters of significance.
- Other duties and responsibilities as assigned.
- Requirements:
- Minimum 3-5 years of experience in the healthcare or managed care industry, including claims/reimbursement experience, professional analytics-related experience and experience working on/managing major projects.
- Minimum 3 years auditing experience in the healthcare industry.
- CPT and ICD coding knowledge.
- Knowledge of Medicare requirements and APC Pricing knowledge.
- Advanced to expert proficiency in the Microsoft Office products, especially Microsoft Word, Microsoft Excel & Microsoft Access.
- Successfully function as an Internal Claims Auditor.
- Able to problem solve, exercise initiative and make medium to high level decisions.
- Thorough understanding of current federal, state and local healthcare compliance requirements.
- Ability to meet deadlines and prioritize tasks; collect, correlate and analyze data.
- Ability to work independently with minimal supervision and as part of a team.
- Must be organized, self-motivated, detail-oriented, disciplined, professional, and a team player.
- Effective written and oral communication.
- WOULD LOVE FOR YOU TO HAVE Bachelor’s degree in healthcare informatics, business administration, or related field, or equivalent in experience and education.
- Certified Professional Coder strongly recommended
- Prior claims processing experience within Eldorado HealthPac Claims Adjudication System is a plus.
- Claim coding experience, coding edits experience and APC Pricing knowledge.
- Benefits:
- Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
- Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
- Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
- Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected.
- Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
- Take Time for Yourself: We offer Flexible Time Off tailored to meet your needs and the needs of the business, helping you achieve work-life balance and meet your personal goals.
- Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
- Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.
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