Remote Medical Claims Processor Auditor

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

Job summary

A leading healthcare company is seeking a Contractual Compliance Coordinator to ensure accuracy in reporting and compliance with regulatory requirements. This fully remote role involves auditing, claims processing, and maintaining contract compliance in managed care. Ideal candidates will have extensive experience in healthcare, strong problem-solving skills, and proficiency in Microsoft Office. Join a team dedicated to improving patient health and operational excellence.

Benefits

Remote work

Health plans

401(k) with match

Insurance

Flexible time off

Parental leave

Professional development

Qualifications

• 3-5 years of experience in healthcare or managed care.
• At least 3 years of healthcare auditing experience.
• Knowledge of Medicare requirements and APC Pricing.

Responsibilities

• Conduct routine monitoring and audits of procedures.
• Generate and submit all required Commercial claims reporting.
• Assist in compliance and auditing responsibilities.

Skills

Problem-solving

Communication

Data analysis

Education

Bachelor’s degree in healthcare informatics

Tools

Microsoft Office

Eldorado HealthPac Claims 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 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.

This position is fully remote, ideally 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. Prepare for annual Health Plan audits.
5. Confirm pricing accuracy in fee tables after downloads.
6. Monitor processes to detect practices resulting in fraud, abuse, or waste.
7. Participate in auditing and submitting appeals and UM Challenges for Reinsurance.
8. Run access queries and impact reports for administrative purposes.
9. Assist in compliance and auditing responsibilities, including pre-payment and post-payment audits.
10. Exercise independent judgment and discretion in significant matters.
11. Perform other duties as assigned.

Qualifications

What You'll Need

• 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 requirements and APC Pricing.
• Proficiency in Microsoft Office, especially Word, Excel, and Access.
• Experience as an Internal Claims Auditor.
• Problem-solving skills, ability to exercise initiative, and make decisions.
• Understanding of healthcare compliance regulations.
• Ability to meet deadlines, analyze data, and work independently or in a team.
• Organized, self-motivated, detail-oriented, professional, and a team player.
• Effective communication skills.

Preferred

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

Additional Information

Our Values: Accountability, Growth & Learning, Innovation, Voice, and Empathy in Action.

Benefits: Remote work, health plans, 401(k) with match, insurance, EAP, flexible time off, parental leave, professional development.

Compensation

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

Equal Opportunity

We are committed to diversity and inclusion, making employment decisions without regard to protected characteristics.

Data Security & Remote Work Requirements

Follow all security policies to protect PHI, PII, and company data. Equipment provided; internet speed of at least 50 Mbps download and 10 Mbps upload recommended.