Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development.
Summary
We are seeking a talented individual who is responsible for full claim overpayment analysis. Assists with identification of claims paid in error and audits paid claims data through multiple tools and methods by utilizing state and federal manuals/regulations, billing and reimbursement policies and practices as well as identifying changes in system edits or new system edits.
Your role in our mission:
Utilizes CMS, State and Client billing and reimbursement policies, client reimbursement practices (through review of manuals/regulations and meetings with stake holders to identify through tried and true queries claim overpayments. Identifications will need to be performed with limited oversight
Participates in the review of paid health insurance claims and member eligibility information to uncover claims overpayment trends
Works with data miners, clinical staff, and stakeholders to identify overpaid claims for each client Use internal and client systems for audit tracking and findings.
Organizes, documents, and communicates results. Collaborates with IT resources as needed
Ensures individual and departmental goals are consistently met or exceeded, in collaboration with other team members and management.
Contributes new ideas for improving existing audit processes and audit queries. Works cohesively with the ideation team and internal clients
Providing feedback to ideation team for trending of provider billing and claims processing by researching client policy and data to reveal new overpayment recovery opportunities
Assists in the identification of new audit concepts
Compiles supporting documents, sample claims and audit approval request form for client approval prior to implementing new audit concept
Research industry clinical standards and guidelines
- Tracks, and follows-up on recoveries
- Excellent verbal and written communication skills
What we're looking for
- 4-6 years of healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, and/or revenue cycle improvement required
Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-9-CM codes, HCPCS codes, CPT codes, DRGs, physician billing, etc.
Experience in healthcare auditing, reviewing and validating the accuracy of claims data and accuracy of claims payment preferred
Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data, Recovery audit experience a plus preferred
- Excellent analytical skills (required) Excellent time management skills (required)
Ability to develop, organize, and maintain project plans and agendas
Knowledge of Medicaid, Medicare and Commercial policy and reimbursement or equivalent healthcare experience (preferred)
What should you expect in this role
- Remote in All USA Locations
- #LINA1
The pay range for this position is $17.00 - $29.00 an hour, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.
Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.
