Remote Medical Claims Processor Auditor

Company Description

WHO IS GUIDEHEALTH? 

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients. 

This position is fully remote but we look for candidates that ideally can work on CST time zone. 

Job Description

As a Contractual Compliance Coordinator, you will ensure the accuracy of the required reporting and procedural and financial claims processing requirements set forth by the client and Health Plan contract requirements for the Value Based Care lines of business. This position is responsible for regulatory and contract compliance in the managed care lines of business.                                                   

WHAT YOU’LL BE DOING

• Conduct routine monitoring and audits of procedures, including but not limited to billing systems audits, Encounter submission audits, and client audits.
• Understand and stay current with client contract criteria and requirements ensuring client services are compliant as well as meet client expectations.
• Generate and submit all required Commercial claims reporting.
• Play a vital role in preparing for the annual Health Plan audits.
• Confirm pricing is correct in the fee tables after the downloads are complete.
• Monitor internal and external processes to detect any practices that, either directly or indirectly, result in fraud, abuse or waste that results in unnecessary costs.
• Participate in auditing and submitting appeals and UM Challenges for Reinsurance process.
• Run access queries and impact reports as needed for administrative purposes.
• Assist coworkers and Internal Auditors in additional compliance and auditing responsibilities, including pre-payment and post-payment audits.
• Consistently exercise independent judgment and discretion in matters of significance
• Other duties and responsibilities as assigned. 

Qualifications

WHAT YOU'LL NEED TO HAVE

• Minimum 3-5 years of experience in the healthcare or managed care industry, including claims/reimbursement experience, professional analytics-related experience and experience working on/managing major projects.
• Minimum 3 years auditing experience in the healthcare industry.
• CPT and ICD coding knowledge.
• Knowledge of Medicare requirements and APC Pricing knowledge.
• Advanced to expert proficiency in the Microsoft Office products, especially Microsoft Word, Microsoft Excel & Microsoft Access.
• Successfully function as an Internal Claims Auditor.
• Able to problem solve, exercise initiative and make medium to high level decisions.
• Thorough understanding of current federal, state and local healthcare compliance requirements.
• Ability to meet deadlines and prioritize tasks; collect, correlate and analyze data.
• Ability to work independently with minimal supervision and as part of a team.
• Must be organized, self-motivated, detail-oriented, disciplined, professional, and a team player.
• Effective written and oral communication.

WOULD LOVE FOR YOU TO HAVE

• Bachelor’s degree in healthcare informatics, business administration, or related field, or equivalent in experience and education.
• Certified Professional Coder strongly recommended
• Prior claims processing experience within Eldorado HealthPac Claims Adjudication System is a plus.
• Claim coding experience, coding edits experience and APC Pricing knowledge.

Additional Information

ALIVE with Purpose: How We Thrive at Guidehealth 

At Guidehealth, our values come to life in everything we do. 

We are Driven by Accountability — grounded in transparency, reliability, and integrity as we navigate challenges and opportunities alike. 

Always Growing, Always Learning — staying curious and continuously improving inspires us to shape a better future for healthcare. 

With Collaborative Innovation, we solve problems creatively, making every experience better for our employees and the patients we serve. 

At Guidehealth, Every Voice Matters — we believe our collective strength is rooted in the un