Remote Managed Care Claims Compliance Coordinator

Guidehealth; Dallas (TX); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare company is seeking a Remote Managed Care Claims Compliance Coordinator. This role involves ensuring compliance with regulatory and contract requirements, conducting audits, and generating claims reporting. Ideal candidates will have extensive experience in healthcare compliance, auditing, and strong analytical skills. The position offers a comprehensive benefits package, including remote work options and professional development resources.

Benefits

Remote work

Health coverage

Retirement plans

Paid parental leave

Professional development resources

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.
• Assist in preparing for annual Health Plan audits.

Skills

Problem-solving

Communication

Decision-making

Education

Bachelor’s degree in healthcare informatics

Tools

Microsoft Office

Eldorado HealthPac Claims Adjudication System

Job description

Remote Managed Care Claims Compliance Coordinator

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 patient health, 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.

Job Description
As a Contractual Compliance Coordinator, you will ensure the accuracy of required reporting and procedural and financial claims processing in compliance with 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.

What You’ll Be Doing

• Conduct routine monitoring and audits of procedures, including billing systems audits, Encounter submission audits, and client audits.
• Understand and stay current with client contract criteria and requirements to ensure compliance and meet expectations.
• Generate and submit all required Commercial claims reporting.
• Assist in preparing for annual Health Plan audits.
• Verify pricing accuracy in fee tables after downloads.
• Monitor processes to detect practices that may result in fraud, abuse, or waste, leading to unnecessary costs.
• Participate in auditing, submitting appeals, and UM Challenges for Reinsurance processes.
• Run access queries and impact reports as needed.
• Assist coworkers and Internal Auditors with compliance and auditing responsibilities, including pre- and post-payment audits.
• Exercise independent judgment and discretion in significant matters.
• Perform other duties as assigned.

Qualifications

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

Preferred Qualifications

• Bachelor’s degree in healthcare informatics, business administration, or related field, or equivalent experience.
• Certified Professional Coder (CPC) certification recommended.
• Experience with Eldorado HealthPac Claims Adjudication System is a plus.
• Claims processing, coding edits, and APC Pricing experience.

Additional Information

At Guidehealth, our values include accountability, continuous learning, collaborative innovation, valuing every voice, and practicing empathy. We offer a comprehensive benefits package, including remote work, health coverage, retirement plans, paid parental leave, and professional development resources. We are committed to diversity and equal opportunity employment. This role involves following security policies to protect PHI and PII and requires reliable internet connectivity meeting specified speed requirements.