Medical Claims Auditor

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate claims for issues related to billing and coding on both a prepayment and retrospective basis.

• Collaborate with Clinical, Claims, and SIU colleagues to prevent incorrect provider payments and combat fraud, waste, and abuse.

• Utilize internal AI tools and predictive models to detect unusual billing patterns, emerging trends, and targeted prepayment audits.

• Work alongside Data Science and Engineering teams to verify AI-flagged claims and provide coding insights to enhance machine learning models.

• Identify opportunities for control and implement systemic prepayment edits to reduce fraud, waste, and abuse.

• Discover audit opportunities through AI-supported data analysis and manual case identification.

• Assist in achieving annual FWA audit objectives by focusing on high-value reviews.

• Facilitate provider discussions regarding FWA audit findings, translating complex data, AI insights, and prepayment denials into compliance feedback.

• Manage the audit workload to ensure timely and precise results within stringent prepayment turnaround periods.

• Collaborate with senior team members and management on specific projects and initiatives.

• Foster partnerships across multidisciplinary teams.

• Navigate Clover systems, perform provider reviews independently, and aid in case/opportunity identification.

⛳️ Requirements

• Over 3 years of experience in coding and auditing.

• Preferred experience with CMS regulations.

• Certified Professional Coder (CPC) credential.

• In-depth understanding of the National Rules of Correct Codification as defined by CMS in the Manual of CCI and the CCI tables.

• Familiarity with working in a technological environment, including claims systems, workflow management tools, Microsoft Office, or Google Suite.

• Previous experience in the health insurance sector.

• Medicare Advantage experience is advantageous.

• Extensive coding knowledge encompassing DME, Outpatient, ASC, and Physician correct coding.

• Awareness of Medicare coding policies.

🏝️ Benefits

• Competitive base salary.

• Equity opportunities.

• Performance-based bonus program.

• 401k matching.

• Regular compensation reviews.

• Comprehensive medical, dental, and vision coverage.

• No-Meeting Fridays.

• Monthly company holidays.

• Mental health resources.

• Generous flexible time-off policy.

• Remote-first culture.

• Learning programs.

• Mentorship opportunities.

• Funding for professional development.

• Consistent performance feedback and reviews.

• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities.

• Reimbursement for office setup expenses.

• Monthly stipend for cell phone and internet.

• Collaboration with global teams.

• Paid parental leave for all new parents.