You will identify discrepancies, prevent overpayments, and ensure adherence to regulatory, contractual, and coding guidelines. This role requires expertise in medical coding, reimbursement methodologies, and healthcare policy to develop and maintain claims editing rules and audit processes. Responsibilities include leading complex claim audits, designing and maintaining claims editing logic, ensuring compliance with CMS, OIG, and other regulations, mentoring junior analysts, and collaborating with IT and policy teams.
Perform pre-pay and post-pay reviews of medical claims for accuracy, medical necessity, and compliance, identifying billing errors such as duplicate claims, unbundling, and upcoding. Detect and support recovery of overpayments and analyze claim patterns to identify systemic issues.
Translate healthcare policies into automated claims editing logic, support configuration of claims editing platforms like Optum CES and TriZetto Facets, and monitor regulatory updates. Analyze large datasets using SQL and Excel to identify trends and root causes of payment errors.
Work cross-functionally with claims, IT, clinical, compliance, and policy teams, serving as a subject matter expert on coding, billing, and payment integrity issues. Communicate findings and recommendations to leadership.
Associate's or Bachelor's degree in Health Administration, Public Health, Business, or related field (or equivalent experience).
5+ years of experience in healthcare claims, payment integrity, auditing, or revenue cycle.
Advanced expertise in coding systems (CPT, HCPCS, ICD-10), reimbursement methodologies, CMS regulations, and claims editing platforms (e.g., Optum CES).
Advanced SQL and data analysis skills.
Experience with Tricare, VA Policy, Medicare, Medicaid, and commercial reimbursement methodologies.
Certifications such as CPC, CCS/CCS-P, RHIT, or RHIA preferred.
Strong leadership, mentorship, analytical, and technical skills.
U.S. citizenship required.
Health Insurance Fully Paid Life Insurance Fully Paid Short- & Long-Term Disability Paid Vacation Paid Sick Leave Paid Holidays Professional Development and Tuition Assistance Program 401(k) Program with Employer Match
Location
N/A
Employment Type
Full-time
Experience Level
Senior
Salary Range
$118,000 - $118,000
Remote work allowed
Yes
Posted
3 weeks ago