Remote Medical Claims Processor Auditor

Minimum 3-5 years of experience in healthcare or managed care industry. Claims/reimbursement experience. Professional analytics-related experience. 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 Microsoft Office (Word, Excel, Access). Ability 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. Ability to collect, correlate, and analyze data. Ability to work independently with minimal supervision and as part of a team. Organized, self-motivated, detail-oriented, disciplined, professional, and a team player. Effective written and oral communication.

Conduct routine monitoring and audits of procedures (billing systems, encounter submission, client audits). Stay current with client contract criteria and requirements for compliance. Generate and submit required Commercial claims reporting. Prepare for annual Health Plan audits. Confirm pricing accuracy in fee tables. Monitor internal and external processes for fraud, abuse, or waste. Participate in auditing and submitting appeals and UM Challenges for Reinsurance. Run access queries and impact reports. Assist coworkers and Internal Auditors with compliance and auditing. Exercise independent judgment and discretion.