Medical Claims Auditor (Remote - Texas)

Medical Claims Auditor (Remote - Texas)

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. 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.

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.

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).

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.