Medical Claims Auditor
Core
Review healthcare claims for billing and coding issues to prevent inaccurate payments and fraud, waste, and abuse (FWA) using AI tools and manual audits.
Role type
Medical Claims Auditor (IC)
Builds
Compliant, effective FWA audit program and prepayment edits
Domain
Healthcare / Medical Coding / Insurance
Deliverable
production ML models
Required skills
Medicare coding policies, DME/Outpatient/ASC/Physician coding, CMS regulations, National Rules of Correct Codification (CCI), claims systems, workflow management tools
Preferred skills
Health insurance experience, Medicare Advantage experience
Technologies
AI tools, predictive models, claims systems, Microsoft Office, Google Suite
Responsibilities
Review claims for billing and coding issues on prepayment and retrospective basis, leverage AI tools to identify anomalous billing patterns, validate AI-flagged claims and provide coding feedback to train ML models, implement systemic prepayment edits, support provider conversations around audit findings, manage audit workload within turnaround times
Seniority
Mid-level, hands-on IC