Remote Medical Claims Processor Auditor

Guidehealth; Chicago (IL); Remote; USD 65,000 - 85,000; Full time

Job summary

A leading healthcare company is seeking a Contractual Compliance Coordinator to ensure compliance with reporting and claims processing. The role involves auditing procedures, understanding client contracts, and supporting compliance responsibilities. Ideal candidates will have extensive experience in healthcare auditing and claims management, with strong analytical and problem-solving skills.

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.
• Support compliance and audit responsibilities.

Skills

Problem-Solving

Decision-Making

Communication

Education

Bachelor’s degree in healthcare informatics

Tools

Microsoft Office

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 who can work CST hours.

Job Description

As a Contractual Compliance Coordinator, you will ensure the accuracy of required reporting, procedural, and financial claims processing in accordance with client and Health Plan contract requirements for the Value-Based Care lines of business. You will be responsible for regulatory and contract compliance within 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 could lead to fraud, abuse, or waste.
• Participate in auditing, submitting appeals, and UM Challenges for Reinsurance.
• Run queries and impact reports as needed.
• Support compliance and audit responsibilities, including pre- and post-payment audits.
• Exercise independent judgment in significant matters.
• Perform other duties as assigned.

Qualifications

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

Preferred

• Bachelor’s degree in healthcare informatics, business administration, or related field.
• Certified Professional Coder (recommended).
• Experience with Eldorado HealthPac Claims System.
• Claims coding and edits experience, APC Pricing knowledge.