Medical Coder

Clinical Editing Dispute Review Analyst 1

Location: Remote

Schedule: Monday–Friday

Job Type: 5 months contract

Job Summary

Responsible for researching, reviewing, and resolving clinical editing inquiries, claims disputes, and appeals. Collaborates with Medical Directors, Claims, Provider Services, and external vendors to ensure accurate claims processing, timely resolution, and appropriate provider reimbursement.

Key Responsibilities

• Research and resolve clinical editing inquiries, claims disputes, and appeals.
• Coordinate with Medical Directors, providers, internal teams, and vendors to obtain necessary information.
• Track inquiries, monitor turnaround times, and maintain review databases and logs.
• Communicate review decisions and resolutions to providers and stakeholders.
• Support claim adjustments, claims research, and appeals processing.
• Prepare weekly metrics, identify trends, and recommend process improvements.
• Ensure accurate documentation and compliance with established procedures.

Minimum Qualifications

• Bachelor's degree and three years of relevant claims operations or customer service experience, or five years of equivalent relevant experience.
• CPC certification preferred; enrollment in a CPC course required within one year if not certified.
• Knowledge of medical coding, claims adjudication, reimbursement methodologies, and clinical editing tools.
• Proficiency in spreadsheets, databases, and claims processing systems.
• Strong analytical, communication, organizational, and problem-solving skills.
• Attention to detail, customer service orientation, and ability to work independently.