Senior Post-Payment Claims Audit Clinician

GuideWell; Florida; Hybrid; USD 78,000 - 126,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Global travel health insurance

Retirement savings plan with employer

Paid time off

Holidays

Wellness program

Job summary

GuideWell seeks a senior-level audit professional to analyze high-risk provider claims post-payment for payment integrity. You will review records for DRG, CPT/HCPCS coding, and contract compliance, coordinating onsite reviews with provider executives to present findings for potential adjustments.

Role requires active clinical certification, extensive coding and claims knowledge, and ability to travel frequently. Hybrid Florida-based role with comprehensive benefits and competitive pay.

Qualifications

• 5+ years related work experience.
• Hold an active clinical certification (e.g. RN, LPN, PA).
• Proficiency with claims processing procedures and provider contracts.

Responsibilities

• Independently perform analysis of high-risk claims on a post-payment basis using clinical, coding and claims processing background.
• Audit high-risk claims for appropriate use of Florida Blue policies and industry standards.
• Review medical records to validate issues on high-risk claims.
• Determine claim-level financial impact based on member benefits and contracts.
• Ensure compliance with Federal, State, BCBS and other guidelines.
• Plan and coordinate onsite reviews with providers.
• Document issues to support claim adjustments with rationale.
• Lead onsite closing meetings with provider executives to communicate findings.
• Identify upstream process gaps driving incorrect payments.

Skills

ICD-9/10 coding

DRG coding

CPT/HCPCS coding

Medical terminology

Claims processing procedures

Provider contracts knowledge

Excel / Word proficiency

Strong communications

Travel willingness

Education

Bachelor's degree or related equivalent experience

Active clinical certification (RN/LPN/PA)

Masters degree (preferred)

Tools

Diamond

Jiva

APT

EIP

Siebel

ICN

Quest

Contract Management System

Burgess

PPS Pricer

AHA Coding Clinic

Encoder

Alineo

Job description

GuideWell seeks a senior-level audit professional to analyze high-risk provider claims post-payment for payment integrity. You will review records for DRG, CPT/HCPCS coding, and contract compliance, coordinating onsite reviews with provider executives to present findings for potential adjustments.

Role requires active clinical certification, extensive coding and claims knowledge, and ability to travel frequently. Hybrid Florida-based role with comprehensive benefits and competitive pay.