Medical Claims Auditor

March 7

Apply Now

Receive Emails with Similar Jobs

Gainwell Technologies

WebsiteLinkedInAll Job Openings

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

• Responsible for processing all casualty or estate functions involving several state Medicaid beneficiaries or deceased Medicaid beneficiaries. • Examine medical claims documentation to verify accuracy and completeness of information. • Apply appropriate coding guidelines to ensure diagnoses, procedures, and services are correctly coded. • Validate appropriateness of claims based on established policies, contracts, and medical guidelines. • Identify and investigate potential billing errors, such as duplicate claims, unbundling, upcoding, and incorrect coding combinations. • Report findings to the Claims Manager or designated supervisor. • Monitor claims processing activities to ensure adherence to legal and regulatory requirements. • Document audit findings and generate comprehensive reports summarizing audit results. • Collaborate with internal stakeholders to resolve claim-related issues and provide guidance on coding requirements. • Stay up-to-date with changes in coding guidelines and best practices. • Assist in implementation and maintenance of quality assurance processes.

🎯 Requirements

• Certification in medical billing/coding (e.g., CPC, CCS) is preferred • 5-7 yrs. experience with third party collections • 3yr experience handling appeals claims in hospital setting, Ability to interpret an Explanation of Benefits (EOB) and UB-04 claim form required. • Working knowledge of Access and SQL also preferred. • Ability to communicate and exchange information • Ability to comprehend and interpret documents and data • Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.) • Requires manual dexterity to use computer, telephone and peripherals • May be required to work extended hours for special business needs • May be required to travel at least 10% of time based on business needs

🏖️ Benefits

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