Medical Claims Auditor I - WFH, USA

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Summary

We are seeking a talented individual for a Medical Claims Auditor I who is responsible for processing all casualty or estate functions involving several state Medicaid beneficiaries or deceased Medicaid beneficiaries.

This includes intake, maintenance, claims review and selection, management, settlement and related functions to the case.

Your role in our mission

Carefully examine medical claims documentation, including medical records, bills, and supporting documents, to verify the accuracy and completeness of information submitted by healthcare providers.

• Apply appropriate coding guidelines (e.g., ICD-10, CPT, HCPCS) to ensure that diagnoses, procedures, and services are correctly coded, in accordance with industry standards and regulatory requirements.
• Validate the appropriateness of claims based on established policies, contracts, and medical guidelines. Identify any discrepancies or inconsistencies and appropriately communicate them for further investigation.
• 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, such as HIPAA, CMS guidelines, and contractual obligations.
• Document audit findings, maintain accurate records, and generate comprehensive reports summarizing audit results, trends, and recommendations for process improvement.
• Collaborate with internal stakeholders, including claims processors, billing specialists, and healthcare providers, to resolve claim-related issues, provide guidance on coding requirements, and address any questions or concerns.
• Stay up-to-date with changes in coding guidelines, industry regulations, and best practices. Participate in training sessions and professional development activities to enhance knowledge and skills.
• Assist in the implementation and maintenance of quality assurance processes to ensure the accuracy, integrity, and efficiency of claims processing operations.
• Contact providers to obtain additional information and / or documentation to resolve unpaid claims, as directed.
• Respond to carrier telephone, fax and e-mail inquiries regarding outstanding claims
• Confer with carriers by telephone or use portals / web sites to determine member eligibility and claim status.
• Update case management system with proper noting of actions and appeal / denial information.
• Generate form letters to carriers to affect payment of outstanding claims.
• Leverage RCM knowledge to assess denials, pursue appeals or close claims when appropriate.
• Work with document imaging system for processing purposes.
• Responsible for achieving high recoveries against a portfolio of claims.
• Responsible for achieving daily, monthly, and quarterly quality and productivity KPIs.

Non-Essential Responsibilities

What we're looking for

Certification in medical billing / coding (e.g., CPC, CCS) is preferred

Minimum Related Work Experience

• 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.

DSM-IV, CPT, HCPCS, and CMS-1500 preferred

• 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

Minimum Education

High School Diploma or equivalent required

What you should expect in this role

Remote in All USA Locations

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The pay range for this position is $20.00 - $25.00 an hour, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development.

All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance.

We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone.

Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth.

Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.

We celebrate diversity and are dedicated to creating an inclusive environment for all employees.