Medicaid Pre-Billing Auditor

AbleLight; Portland (OR); Vor Ort; USD 95.000 - 105.000; Vollzeit

Benefits dieser Stelle

Health Insurance

403(b) Retirement Savings Plan

Paid Time Off

Any Day Pay via Dayforce Wallet

Zusammenfassung

AbleLight is seeking an experienced Auditor/Compliance professional to review Medicaid claims, documentation, and billing accuracy. The role emphasizes risk-based audits, regulatory compliance, and cross-functional collaboration in a health services setting.

Candidates should hold a relevant degree and several healthcare auditing credentials (CPC/CCS-P/CPMA/CHC) with at least five years of experience. Competitive benefits and a focus on total well-being are offered.

Qualifikationen

• 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.
• Certifications in healthcare coding, audit, compliance, or health information (see required credentials).

Aufgaben

• Audit Medicaid claims and records, including risk-based, prospective, and retrospective reviews.
• Evaluate documentation against payer requirements and enforce billing holds when needed.
• Assess coding and billing accuracy using CPT, HCPCS, ICD-10-CM, Medicaid, waiver, managed-care, and state rules.
• Prepare and maintain audit reports with objectives, criteria, methodology, and conclusions.
• Suggest corrective actions and track progress with leadership and stakeholders.
• Collaborate with various departments to implement audit-management and analytics tools.

Kenntnisse

Auditing

Regulatory compliance

Healthcare audits

Ausbildung

Bachelor's degree

CPC

CCS-P

CPMA

CHC

Other credential

Jobbeschreibung

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

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; or
• Certified Coding Specialist–Physician-based (CCS-P) through AHIMA; or
• Certified Professional Medical Auditor (CPMA); or
• Certified in Healthcare Compliance (CHC); or
• Another relevant healthcare coding, audit, compliance, or health information credential

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 employment and 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
• Training program 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.
• Pay: $95,000 - $105,000

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