Medical Claims Auditor (Remote - Texas)

About the role

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.

Responsibilities

• 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.

Requirements

• HS Diploma/GED Required
• 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).

Qualifications

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.

Skills

Strong knowledge of insurance policy types (HMO, PPO, EPO, Medicare, Medicaid) and the medical claims lifecycle, including denials management and appeals.

Benefits

Gainwell Technologies offers a variety of benefits including a generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. Salaried, full-time candidates are eligible for these benefits.

Pay

The pay range for this position is $50,000 - $55,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

Schedule

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.