Medicaid Pre-Billing Auditor

Colonial Group; Fresno, Northern (CA, KY); Hybrid; USD 85,000 - 110,000; Full time

Benefits offered by this job

Health insurance

403(b) Retirement Savings Plan with 3.

Paid Time Off (PTO)

Tuition Reimbursements

CPR certification training

Career Development training

Any Day Pay with Dayforce Wallet

Career development opportunities

Any Day Pay with Dayforce Wallet

Job summary

AbleLight is seeking a Medicaid Pre-Billing Auditor to independently review Medicaid claims, coding and documentation. Remote role for candidates in CA, CO, MN, WA, OR or MO, with focus on pre-billing audits and reducing regulatory risk.

Strong emphasis on auditing accuracy and cross-functional collaboration. Requirements include a Bachelor’s in healthcare administration or accounting and 5+ years in auditing, with CPC/CCS-P/CPMA/CHC or equivalent credentials.

Qualifications

• Bachelor’s degree in healthcare administration, accounting or related field.
• Five+ years of auditing or related experience.
• Credentials such as CPC, CCS-P, CPMA, CHC or equivalent.

Responsibilities

• Audit Medicaid claims and records on a risk-based, prospective and retrospective basis.
• Impose internal billing holds when pre-billing audits find non-compliant documentation.
• Evaluate coding and billing accuracy across CPT, HCPCS, ICD-10-CM.
• Prepare concise audit reports and oversee corrective actions and follow-up.
• Escalate overpayments and monitor remediation and remediation steps.

Skills

Auditing

Regulatory compliance

Data analytics

AI-assisted auditing

Education

Bachelor’s degree in healthcare administration or accounting

Equivalent combination of education and experience

CPMA

CHC

Other healthcare credential

Tools

Audit-management platforms

Compliance-monitoring software

Analytics tools

Job description

Put Your Heart to Work!

At AbleLight, we believe theworldshinesbrighterwhen people with developmental disabilities achieve their full potential. We pioneer life-changing services that empower the people we serve to thrive.

The Medicaid Pre-Billing Auditor independently evaluates Medicaid billing, coding, authorizations, service documentation, and related reimbursement practices to determine whether claims are accurate, properly coded, and compliant with federal and state requirements. A primary focus will be pre-billing audits. The role identifies billing risks, imposes billing holds before defective billing is initiated, recommends corrective actions, and monitors remediation to reduce regulatory risk. Limited reviews involving commercial payers may also be performed based on organizational need.

This position is remote, but we are looking for candidates based in Colorado, California, Minnesota, Washington, Oregon or Missouri.

Requirements

• Bachelor’s degree in healthcare administration, accounting or a related field; or an equivalent combination of relevant education and experience.
• Minimum of five years of experience in auditing or a related function, including direct experience reviewing claims, coding, and supporting documentation for accuracy and regulatory compliance.
• One of the following:
  • Certified Professional Coder (CPC) through AAPC;
  • Certified Coding Specialist–Physician-based (CCS-P) through AHIMA;
  • Certified Professional Medical Auditor (CPMA);
  • Certified in Healthcare Compliance (CHC);
  • Another relevant healthcare coding, audit, compliance, or health information credential

Benefits:

We support the whole person and have designed our benefits with you and your family's total well-being in mind:

• Health and Wellness: Medical, Dental, and Vision benefits starting the first of the month following 30 days of employmentand access to Teledoc
• Financial Wellness: 403(b) Retirement Savings Plan with 3.5% matching contributions, Health Savings Account, Flexible Savings Account, and Basic Life, AD&D, STD, and LTD insurance
• Work/Life Balance: Paid Time Off (PTO), Tuition Reimbursements
• Trainingprogram will allow you to become CPR certified
• Ongoing training to support Career Development
• We are now also offering Any Day Pay. With Dayforce Wallet, you get access to your pay as soon as you've earned it at no additional cost to you.

Responsibilities:

• Auditing and Monitoring (70%)

  • Conduct risk-based, prospective, and retrospective audits of Medicaid claims and records.
  • Determine whether documentation meets payer requirements. Impose internal billing holds where pre-billing audits find documentation does not meet billing standards.
  • Evaluate coding and billing accuracy using applicable CPT, HCPCS, ICD-10-CM, Medicaid program, waiver, managed-care, and state-specific requirements.
  • Support billing-related risk assessments, investigations, payer audits, government inquiries, and compliance reviews as assigned.
  • Promptly escalation suspected overpayments and other significant concerns in accordance with organization procedures.

• Reporting and Corrective Action (10%)

  • Maintain complete and defensible audit reports documenting audit objectives, criteria, methodology, samples, evidence reviewed, exceptions, conclusions, and reviewer decisions.
  • Analyze findings to identify patterns, control weaknesses, potential financial exposure, and opportunities for process improvement.
  • Prepare concise written reports, dashboards, and presentations that communicate findings and recommended actions to Compliance leadership and appropriate stakeholders.
  • Recommend practical corrective actions and collaborate with accountable leaders to establish responsibilities, target dates, and validation measures.
  • Monitor corrective-action progress, perform follow-up testing, and determine whether remediation is effective and sustainable.
  • Maintain records of findings, corrective actions, management responses, and closure evidence.

• Cross-Functional Collaboration and Audit Technology (10%)

  • Work collaboratively with various departments while preserving the objectivity of the Compliance audit function.
  • Help evaluate and implement audit-management platforms, compliance-monitoring software, analytics tools, dashboards, and automated exception-reporting capabilities.
  • Use approved data analytics and AI-assisted auditing technologies to analyze claims and documentation, identify outliers, prioritize higher-risk records, recognize recurring patterns, and expand audit coverage.

• Consultation and Regulatory Support (10%)

  • Serve as a subject-matter resource on Medicaid billing, coding, documentation, reimbursement, and audit requirements.
  • Monitor relevant Medicaid billing manuals, waiver requirements, regulatory updates, payer guidance, coding changes, and enforcement activity.
  • Identify education needs arising from audit results and provide content expertise to various departments.
  • Assist with the development or revision of organization policies and procedures