Medical Claims Auditor

Imagine360 is seeking a Medical Claims Auditor to join the team! The Medical Claims Auditor is responsible for assisting with our business process review to ensure accurate payment and operational efficiencies. The Medical Claims Auditor will review professional and facility claims for accuracy and compliance with industry standard guidelines and contractual language on behalf of our clients. The Medical Claims Auditor must demonstrate a coder's aptitude, proficiency and knowledge of coding guidelines and reimbursement methodologies for all types of services from the payer's perspective.

Position Location: 100% remote

Responsibilities include but are not limited to:

• Review professional and facility claims for accuracy and apply standard coding rules, guidelines, and conventions.
• Review supporting documentation, analyze medical records and itemized bills to validate appropriateness of billing and coding procedures.
• Review contracts and apply contractual adjustments to the medical charges.
• Audit codes and services performed by providers according to ICD-10, CPT, HCPCS and CMS Guidelines.
• Apply appropriate reimbursement methodology.
• Ensure accuracy of work product.
• Proficient in meeting quality and quantity standards.
• Able to learn and properly utilize proprietary software programs essential to support the job function.
• Learn to properly utilize proprietary software programs essential to support the job function.
• Adhere to HIPAA guidelines and regulations.
• Provide support and back up within the department and cross-functionally.
• Ability to work well in an individual and team environment.
• Meet and or exceed daily production and quality goals and performance objectives.
• Other duties as needed.

Required Experience/Education:

• High School Diploma or equivalent required
• Minimum 2 years Claims Coding or Medical Billing experience required
• Medicare Reimbursement / Denial experience
• Prior experience in the Self-Funded Industry

Skills and Abilities:

• Knowledge and understanding of CMS-1500 and UB-04 Medical Claim Forms.
• Medicare reimbursement/denial experience preferred.
• Communication (written, verbal, and listening), interpersonal and analytic skills.
• Ability to use software related to job responsibilities including MS Office with proficiency in Excel and Outlook.
• Strong attention to detail.
• Ability to maintain a grasp of business and departmental process rules.
• Ability to produce quality work while meeting production goals.
• Coding / Nursing Certification and ICD-10 proficiency is required.
• Familiarity with CMS/Medicare
• Familiarity with rev codes, HCPCS, DRG

Licenses or Certifications:

• Coding Certification (CPC, CCA, CCS, RHIA, etc.) and / or Nursing Licensure (RN, LPN, etc.)

What can Imagine360 offer you?

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives

Want to see our latest job opportunities? Follow us on LinkedIn

Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**