Remote Contractual Compliance Coordinator

ZipRecruiter; Missouri City (TX); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare company is seeking a Contractual Compliance Coordinator to ensure compliance with reporting and claims processing requirements. This fully remote role involves auditing, regulatory compliance, and collaboration with internal teams. Ideal candidates will have experience in healthcare auditing and strong analytical skills. The position offers competitive benefits and supports professional growth.

Benefits

Work from Home

Health coverage

401(k) plan with employer match

Employee Assistance Program

Flexible Time Off policy

Paid parental leave

Resources for learning and development

Qualifications

• 3-5 years of experience in healthcare or managed care.
• At least 3 years of healthcare auditing experience.
• CPT and ICD coding knowledge.

Responsibilities

• Conduct routine monitoring and audits of procedures.
• Generate and submit all required Commercial claims reporting.
• Monitor processes to detect fraud, abuse, or waste.

Skills

Problem-solving

Communication

Analytical

Education

Bachelor’s degree in healthcare informatics

Tools

Microsoft Office

Eldorado HealthPac Claims Adjudication System

Job description

WHO IS GUIDEHEALTH?

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.

This position is fully remote, ideally for candidates available to work on CST time zone.

Job Description

As a Contractual Compliance Coordinator, you will ensure the accuracy of reporting, procedural, and financial claims processing requirements set forth by the client and Health Plan contract requirements for the Value Based Care lines of business. This role is responsible for regulatory and contract compliance in managed care lines of business.

WHAT YOU’LL BE DOING

1. Conduct routine monitoring and audits of procedures, including billing systems audits, Encounter submission audits, and client audits.
2. Understand and stay current with client contract criteria and requirements to ensure compliance and meet client expectations.
3. Generate and submit all required Commercial claims reporting.
4. Assist in preparing for the annual Health Plan audits.
5. Confirm pricing accuracy after downloads are complete.
6. Monitor processes to detect practices that result in fraud, abuse, or waste, leading to unnecessary costs.
7. Participate in auditing and submitting appeals and UM Challenges for Reinsurance.
8. Run access queries and impact reports for administrative purposes.
9. Assist coworkers and Internal Auditors with compliance and auditing responsibilities, including pre- and post-payment audits.
10. Exercise independent judgment and discretion in significant matters.
11. Perform other duties as assigned.

WHAT YOU'LL NEED TO HAVE

1. 3-5 years of experience in healthcare or managed care, including claims/reimbursement, analytics, and project management.
2. At least 3 years of healthcare auditing experience.
3. CPT and ICD coding knowledge.
4. Knowledge of Medicare requirements and APC Pricing.
5. Proficiency in Microsoft Office, especially Word, Excel, and Access.
6. Experience as an Internal Claims Auditor.
7. Problem-solving skills, initiative, and decision-making ability.
8. Understanding of healthcare compliance regulations.
9. Ability to meet deadlines, analyze data, and work independently or in a team.
10. Organized, self-motivated, detail-oriented, professional, and a team player.
11. Effective communication skills.

WOULD LOVE FOR YOU TO HAVE

1. Bachelor’s degree in healthcare informatics, business administration, or related field, or equivalent experience.
2. Certified Professional Coder (strongly recommended).
3. Claims processing experience with Eldorado HealthPac Claims Adjudication System.
4. Claim coding, coding edits, and APC Pricing experience.

Additional Information

BENEFITS:

• Work from Home: Fully remote with provided equipment.
• Health coverage: Medical, Dental, Vision plans.
• Retirement: 401(k) plan with 3% employer match.
• Insurance: Life and voluntary Life insurance options.
• Support: Employee Assistance Program (EAP).
• Time Off: Flexible Time Off policy.
• Parental Leave: Paid leave for new parents.
• Professional Growth: Resources for learning and development.

COMPENSATION:

Paid bi-weekly, dependent on skills, experience, education, location, and certifications.

OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT

Guidehealth values diversity and is an equal opportunity employer. We do not discriminate based on various protected categories.

OUR COMMITMENT TO DATA PROTECTION

This role requires adherence to security policies to protect PHI, PII, and company data.

REMOTE WORK TECHNICAL REQUIREMENTS

Employees must have reliable internet (minimum 50 Mbps download, 10 Mbps upload) and necessary equipment provided by Guidehealth.