Medical Claims Auditor
Core
Review healthcare claims for billing and coding issues to prevent inaccurate payments and fraud, waste, and abuse (FWA) using manual audits and AI-assisted data analysis.
Role type
Medical Claims Auditor (IC)
Builds
Compliant, effective FWA audit program and prepayment edits
Domain
Healthcare / Insurance / Medicare
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, AI tools usage
Technologies
Claims systems, workflow management tools, 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 to train machine learning models, implement systemic prepayment edits, manage audit workload within strict turnaround times, support provider conversations regarding audit findings
Seniority
Mid-level, hands-on IC