医疗理赔审计员 (远程 - 德克萨斯州) (任何城市, TX, US, 99999)
Medical Claims Auditor (Remote - Texas) (Any city, TX, US, 99999)
优秀的企业需要优秀的团队来推动运营。加入我们，解决业务挑战，提升我们的工作和成长方式。在Gainwell工作有其独特的回报。你将有机会在一个重视你的贡献、注重工作灵活性、学习和职业发展的公司中成长。
职位简介
医疗理赔审计员负责审查和分析医疗理赔，以确保准确性、合规性并遵守公司和监管标准。该职位涉及审计供应商提交的理赔，验证编码准确性，并识别理赔提交中的错误或差异。理想的候选人具备良好的细节关注能力，对医疗计费和编码有扎实的理解，并在医疗或医院环境中具有申诉或报销流程的经验。
你在我们使命中的职责
- 审查医疗理赔、支持文件和医疗记录，确保完整性和符合公司政策及行业标准。
- 使用ICD-10、CPT和HCPCS指南验证编码准确性。
- 解释和分析费用说明（EOB）和UB-04理赔表，以核实正确的计费和付款数据。
- 识别并记录差异，如重复理赔、拆分服务、高估收费和其他计费错误。
- 向理赔处理团队或管理层传达审计结果并推荐纠正措施。
- 应用审计方法和监管指南（CMS、Medicaid、Medicare和保险公司合同）以确保理赔完整性。
- 支持流程改进，以提高理赔准确性和减少计费错误。
我们寻找的人选
- 需要高中文凭/GED
- 至少三年直接医疗理赔回收经验，包括保险跟进和追收工作。
- 熟悉保险险种类型（HMO、PPO、EPO、Medicare、Medicaid）和医疗理赔生命周期，包括拒付管理和申诉。
- 对费用说明（EOBs）和医疗计费表UB-04和HCFA-1500有深入理解。
- 有使用保险公司门户和健康信息系统（如Availity、Navinet）获取理赔、患者和报销信息的经验。
- 具备处理大量联系的能力，包括每天与供应商和保险公司进行30次以上的沟通，以解决拒付、差异和
查看英文原文
Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development.
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
- 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).
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.
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. 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 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), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
Originally posted on Himalayas