Medical Claims Auditor I - Remote US id-7493

April 28, 2025

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

We are seeking a talented individual for a Medical Claims Auditor I who is responsible for processing all casualty or estate functions involving several state Medicaid beneficiaries or deceased Medicaid beneficiaries. This includes intake, maintenance, claims review and selection, management, settlement and related functions to the case.

Other Jobs You May Be Interested In

Your role in our mission

Carefully examine medical claims documentation, including medical records, bills, and supporting documents, to verify the accuracy and completeness of information submitted by healthcare providers.

Apply appropriate coding guidelines (e.g., ICD-10, CPT, HCPCS) to ensure that diagnoses, procedures, and services are correctly coded, in accordance with industry standards and regulatory requirements.

Validate the appropriateness of claims based on established policies, contracts, and medical guidelines. Identify any discrepancies or inconsistencies and appropriately communicate them for further investigation.

Identify and investigate potential billing errors, such as duplicate claims, unbundling, upcoding, and incorrect coding combinations. Report findings to the Claims Manager or designated supervisor.

Monitor claims processing activities to ensure adherence to legal and regulatory requirements, such as HIPAA, CMS guidelines, and contractual obligations.

Document audit findings, maintain accurate records, and generate comprehensive reports summarizing audit results, trends, and recommendations for process improvement.

Collaborate with internal stakeholders, including claims processors, billing specialists, and healthcare providers, to resolve claim-related issues, provide guidance on coding requirements, and address any questions or concerns.

Stay up-to-date with changes in coding guidelines, industry regulations, and best practices. Participate in training sessions and professional development activities to enhance knowledge and skills.

Assist in the implementation and maintenance of quality assurance processes to ensure the accuracy, integrity, and efficiency of claims processing operations.

Contact providers to obtain additional information and/or documentation to resolve unpaid claims, as directed.

Respond to carrier telephone, fax and e-mail inquiries regarding outstanding claims

Confer with carriers by telephone or use portals/web sites to determine member eligibility and claim status.

Update case management system with proper noting of actions and appeal/denial information.

Generate form letters to carriers to affect payment of outstanding claims.

Leverage RCM knowledge to assess denials, pursue appeals or close claims when appropriate.

Work with document imaging system for processing purposes.

Responsible for achieving high recoveries against a portfolio of claims.

Responsible for achieving daily, monthly, and quarterly quality and productivity KPIs.

Non-Essential Responsibilities

What we're looking for

Certification in medical billing/coding (e.g., CPC, CCS) is preferred

Minimum Related Work Experience

5-7 yrs. experience with third party collections

3yr experience handling appeals claims in hospital setting, Ability to interpret an Explanation of Benefits (EOB) and UB-04 claim form required. DSM-IV, CPT, HCPCS, and CMS-1500 preferred

Working knowledge of Access and SQL also preferred. Ability to communicate and exchange information

Ability to comprehend and interpret documents and data

Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)

Requires manual dexterity to use computer, telephone and peripherals

May be required to work extended hours for special business needs

May be required to travel at least 10% of time based on business needs

Minimum Education

High School Diploma or equivalent required

Back to blog

Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

DISCLAIMER