Medical Claims Coding Auditor
All Care To You
full-time
Posted on:
Location Type: Remote
Location: Remote • California • 🇺🇸 United States
Visit company websiteSalary
💰 $60,000 - $100,000 per year
Job Level
Mid-LevelSenior
About the role
- Support the Managed Service Organization (MSO) by performing detailed medical claims reviews to ensure accuracy, compliance, and appropriate reimbursement across Medicare, Commercial, and Medicaid lines of business.
- Focus on validating diagnosis and procedure coding, identifying improper billing or documentation, and supporting medical necessity determinations in alignment with CMS and payer-specific guidelines.
- Serve as a key liaison between care management and claims operations to promote coding accuracy and support efficient payment processes within value-based care arrangements.
- Review provider medical records to validate the following claim data: Codes billed are accurate, complete, and comply with MSO and payer policies; Codes billed comply with bundling and unbundling guidelines and global period policies; ICD-10 codes are chosen appropriately and to the highest level of specificity; CPT and HCPCS codes accurately report the services rendered including level of E&M code in accordance with AMA, CMS, and state-specific coding standards; Documentation supports billed services under Medicare, Medicaid, and Commercial payer rules.
- Identify and report potential coding errors, documentation gaps, or billing inconsistencies that impact reimbursement or compliance.
- Collaborate with nurses, medical director, and claims teams to adjudicate/deny claims with coding and/or documentation errors.
- Support retrospective and prospective reviews to improve claims accuracy and reduce preventable denials.
- Participate in internal audits, education sessions, and process improvement initiatives to enhance coding integrity.
- Stay current on updates to CMS regulations, payer billing policies, and industry coding changes.
- Protect member and provide confidentiality by adhering to HIPAA and MSO compliance standards.
Requirements
- Minimum 3 years of professional and facility coding experience, including claim review within a Managed Service Organization, health plan, or large provider network.
- Demonstrated knowledge of Medicare, Commercial, and Medicaid coding, billing, and reimbursement requirements.
- Familiarity with risk adjustment and value-based care models preferred.
- Proficient with EHR and claims management systems (e.g., Epic, Cerner, IDX, or payer portals).
- Strong knowledge of medical terminology, anatomy, physiology, and healthcare regulations.
- Experience with utilization management, claims auditing, and payment integrity programs.
- Working knowledge of MCG, InterQual, and CMS National Coverage Determinations (NCDs)/Local Coverage Determinations (LCDs).
- Working knowledge of DRG.
- Prior experience collaborating with provider groups in an MSO or IPA environment.
Benefits
- 100% employer paid medical, vision, dental, and life coverage for our employees.
- Paid holiday, sick, birthday, and vacation time.
- 401k matching plan.
- Additional employee paid coverage options available.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
medical claims reviewdiagnosis codingprocedure codingICD-10 codingCPT codingHCPCS codingclaims auditingutilization managementpayment integrityrisk adjustment
Soft skills
collaborationcommunicationattention to detailproblem-solvinganalytical skillsorganizational skillsinterpersonal skillsprocess improvementeducation and trainingconfidentiality