Medical Claims Auditor

TalentHop; United States; Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical coverage

401(k) matching

Performance bonus

Parental leave

Flexible PTO

Remote-first

Stock purchase plan

Job summary

TalentHop in the United States is seeking a Medical Claims Auditor to help safeguard payment integrity in FWA programs. You will review claims for proper coding, support AI-driven detection, and collaborate with data teams to refine audit processes.

The role emphasizes accuracy, regulatory compliance, and clear communication with providers. A CPC certification and CMS/NCCI experience are highly valued, with remote-first work flexibility.

Qualifications

• Minimum 3 years coding and auditing experience; CMS regulations experience preferred.
• Certified Professional Coder (CPC) certification.
• Strong knowledge of National Correct Coding Initiatives as defined by CMS.
• Experience with claims systems, workflow tools, and Microsoft Office or Google Suite.
• Prior health insurance experience; Medicare Advantage experience is a plus.

Responsibilities

• Review claims for billing and coding issues on prepayment and retrospective bases.
• Use AI tools and predictive models to identify suspicious billing patterns.
• Collaborate with Data Science and Engineering teams to validate AI-flagged claims.
• Identify and implement systemic prepayment edits to mitigate FWA.
• Support annual audit goals by prioritizing high-value claim reviews.
• Communicate audit findings clearly to providers and internal teams.
• Manage audit workload to ensure timely and accurate results.
• Participate in targeted projects and initiatives with senior team members.
• Build trust and partnerships across multi-disciplinary teams.

Skills

Medical coding

Auditing

CMS regulations

CPC certified

NCCI knowledge

Claims systems

Office tools

Medicare Advantage

Tools

Microsoft Office

Google Suite

Claims workflow tools

Job description

The organization operates within the healthcare insurance industry, addressing challenges related to healthcare fraud, waste, and abuse (FWA). It focuses on integrating compliance, payment integrity, and data infrastructure to monitor, identify, and investigate FWA effectively. The team leverages technology and data-driven approaches to improve healthcare payment accuracy and enhance audit programs, contributing to more efficient healthcare delivery.

About the Opportunity:

The MEDICAL CLAIMS AUDITOR role involves ensuring the integrity and compliance of the FWA audit program by reviewing medical claims for correct coding and billing practices. This position supports the organization’s efforts to prevent improper payments and detect fraud through collaboration, data analysis, and the application of internal AI tools. The role is critical in refining audit processes and providing actionable compliance feedback that helps maintain regulatory standards.

Responsibilities:

• Review claims for billing and coding issues on prepayment and retrospective bases.
• Use AI tools and predictive models to identify suspicious billing patterns.
• Collaborate with Data Science and Engineering teams to validate AI-flagged claims.
• Identify and implement systemic prepayment edits to mitigate FWA.
• Support annual audit goals by prioritizing high-value claim reviews.
• Communicate audit findings clearly to providers and internal teams.
• Manage audit workload to ensure timely and accurate results.
• Participate in targeted projects and initiatives with senior team members.
• Build trust and partnerships across multi-disciplinary teams.

Requirements:

• Minimum 3 years coding and auditing experience; CMS regulations experience preferred.
• Certified Professional Coder (CPC) certification.
• Strong knowledge of National Correct Coding Initiatives as defined by CMS.
• Experience with claims systems, workflow tools, and Microsoft Office or Google Suite.
• Prior health insurance experience; Medicare Advantage experience is a plus.

Pay Range and Compensation Package:

• The pay range and compensation package for this role will be determined based on the candidate's experience, skills, and other relevant factors.
• Comprehensive medical, dental, and vision coverage.
• 401k matching.
• Performance-based bonus program.
• Paid parental leave for all new parents.
• Flexible time off and mental health resources.
• Remote-first work culture with stipends for office setup and communications.
• Employee Stock Purchase Plan offering discounted equity opportunities.

Equal Opportunity Statement:

Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin.