Medical Claims Auditor (Remote - Texas)

Summary

The Medical Claims Auditor is responsible for reviewing and analyzing medical claims to ensure accuracy, compliance, and adherence to company and regulatory standards. This role involves auditing provider-submitted claims, validating coding accuracy, and identifying errors or discrepancies in claim submissions. The ideal candidate has strong attention to detail, a solid understanding of medical billing and coding, and experience with appeals or reimbursement processes in a healthcare or hospital setting.

Your role in our mission

• Review medical claims, supporting documentation, and medical records to ensure completeness, accuracy, and compliance with company policies and industry standards.
• Validate coding accuracy using ICD-10, CPT, and HCPCS guidelines.
• Interpret and analyze Explanation of Benefits (EOB) and UB-04 claim forms to verify correct billing and payment data.
• Identify and document discrepancies such as duplicate claims, unbundled services, upcoding, and other billing errors.
• Communicate audit findings and recommend corrective actions to the claims processing team or management.
• Apply auditing methodologies and regulatory guidelines (CMS, Medicaid, Medicare, and payer contracts) to ensure claims integrity.
• Support process improvements to enhance claim accuracy and reduce billing errors.

What we're looking for

• Minimum of three (3) years of direct medical claims collections experience, including insurance follow-up and recovery efforts.
• Strong knowledge of insurance policy types (HMO, PPO, EPO, Medicare, Medicaid) and the medical claims lifecycle, including denials management and appeals.
• Advanced understanding of Explanation of Benefits (EOBs) and medical billing forms UB-04 and HCFA-1500.
• Experience navigating payer portals and health information systems (e.g., Availity, Navinet) to obtain claim, patient, and reimbursement information.
• Demonstrated ability to perform high-volume outreach and communication, including 30+ daily contacts with providers and insurance carriers to resolve denials, discrepancies, and recoveries (including Medicaid reclamation).

What you should expect in this role

• This is a remote position for candidates residing in Texas.
• Work schedule is Monday – Friday, from 7:00 AM – 4:30 PM.
• Video cameras must be used during all interviews, as well as during the initial week of orientation.
• To work effectively as a teleworker or hybrid positions with Gainwell, employees must have a broadband internet connection with a minimum speed of 24 Mbps download and 8 Mbps upload. Higher speeds are recommended for optimal performance.
• To test your internet speed, go to Google and search for “Internet Speed Test.”

This posting is intended for pipelining. We will accept applications on an ongoing basis.

#LI-REMOTE #LI-JA1 #LI-CM1