Medical Claims Auditor I - Remote, USA

About the position

The Medical Claims Auditor I position at Gainwell is responsible for processing casualty or estate functions related to Medicaid beneficiaries, including claims review, management, and settlement. The role involves verifying the accuracy of medical claims documentation, applying coding guidelines, and ensuring compliance with legal and regulatory requirements. The auditor will collaborate with internal stakeholders to resolve claim-related issues and maintain quality assurance processes.

Responsibilities
? Examine medical claims documentation to verify accuracy and completeness.
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? Apply coding guidelines (ICD-10, CPT, HCPCS) to ensure correct coding of diagnoses and procedures.
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? Validate claims based on established policies and medical guidelines, identifying discrepancies.
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? Investigate potential billing errors and report findings to the Claims Manager.
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? Monitor claims processing activities for adherence to legal and regulatory requirements.
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? Document audit findings and generate reports summarizing results and recommendations.
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? Collaborate with internal stakeholders to resolve claim-related issues and provide guidance on coding requirements.
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? Stay updated with changes in coding guidelines and participate in professional development activities.
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? Assist in implementing quality assurance processes for claims processing operations.
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? Contact providers for additional information to resolve unpaid claims.
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? Respond to inquiries regarding outstanding claims from carriers.
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? Update case management system with actions and appeal/denial information.
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? Generate form letters to carriers for payment of outstanding claims.
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? Leverage RCM knowledge to assess denials and pursue appeals.
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? Work with document imaging system for processing purposes.
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? Achieve high recoveries against a portfolio of claims and meet quality and productivity KPIs.

Requirements
? Certification in medical billing/coding (e.g., CPC, CCS) preferred.
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? 5-7 years of experience with third-party collections.
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? 3 years of experience handling appeals claims in a hospital setting.
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? Ability to interpret an Explanation of Benefits (EOB) and UB-04 claim form required.
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? Working knowledge of Access and SQL preferred.
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? Ability to communicate and exchange information effectively.
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? Ability to comprehend and interpret documents and data.

Nice-to-haves
? Experience with DSM-IV, CPT, HCPCS, and CMS-1500 preferred.

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

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