Healthcare Claims Auditor & Compliance Analyst

Acentra Health, LLC; Oregon; On-site; USD 62,000 - 69,000; Full time

Job summary

Acentra Health, LLC is seeking a Medical Claims Reviewer to support healthcare claims administration, auditing, and policy interpretation. The role focuses on reviewing claims, reimbursement issues, coding compliance, and operational improvements across diverse healthcare programs.

The position requires a Bachelor's degree or equivalent, 2+ years of relevant experience, and strong analytical and communication skills. Team collaboration and policy development are key aspects of the role.

Qualifications

• Bachelor's degree or equivalent combination of experience and education.
• 2+ years experience in medical claims review, healthcare operations, compliance, medical coding and billing, healthcare program administration, or related healthcare functions.
• Knowledge of healthcare regulations, medical terminology, coding systems, auditing concepts, billing procedures, and documentation requirements.
• Understanding of healthcare claims processing systems and claims administration processes.
• Strong analytical, problem-solving, process improvement, and communication skills.

Responsibilities

• Review claims, medical records, billing information, and supporting documentation to determine coverage and reimbursement.
• Audit claims and records for compliance with coding guidelines, reimbursement requirements, regulations, policies, and program rules.
• Identify and investigate billing irregularities, errors, coding concerns, documentation deficiencies, and potential fraud or abuse.
• Resolve denied claims, billing appeals, provider disputes, reimbursement issues, exception requests, and coverage inquiries.
• Research and respond to questions related to coding, compliance, reimbursement, coverage, billing, and documentation requirements.
• Manage inpatient and outpatient claim reviews and ensure timely reimbursement determinations.
• Serve as a resource to providers, internal staff, contractors, and other stakeholders.
• Interpret regulations, statutes, administrative rules, guidance, and policies related to claims and operational issues.
• Research and resolve program-related questions and provide technical assistance.
• Prepare reports, analyses, recommendations, issue summaries, and written interpretations.

Skills

2+ years in medical claims review

Healthcare operations experience

Regulatory & coding knowledge

Analytical & problem-solving skills

Communication skills

Education

Bachelor's degree or equivalent

Job description

Acentra Health, LLC is seeking a Medical Claims Reviewer to support healthcare claims administration, auditing, and policy interpretation. The role focuses on reviewing claims, reimbursement issues, coding compliance, and operational improvements across diverse healthcare programs.

The position requires a Bachelor's degree or equivalent, 2+ years of relevant experience, and strong analytical and communication skills. Team collaboration and policy development are key aspects of the role.