Internal Claims Auditor

WHO IS GUIDEHEALTH?

At Guidehealth, our mission is to enhance healthcare affordability for patients and restore the fulfillment of practicing medicine for providers. As a physician-led company, we recognize that streamlining administrative tasks and harnessing the power of predictive analytics and AI enable our partner physician practices prioritizing delivering high-quality healthcare focused on outcomes and value.

Driven by empathy, we empower physicians to anticipate the needs of patients requiring more attention, strengthen connections between patients and physicians with virtually-embedded Healthguides, and leverage AI and analytics to proactively avoid preventable events. This approach results in increased levels of patient and practice engagement, ultimately leading to more significant positive impacts on patients.

Join us as we put healthcare on a better path!!

As an Internal Claims Auditor, you will ensure the accuracy of the required reporting and 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 position is responsible for regulatory and contract compliance in the managed care environment.

WHAT YOU’LL BE DOING

• Conducting routine monitoring and audits of procedures, including but not limited to billing systems audits, Encounter submission audits, and client audits.
• Understanding and staying current with client contract criteria and requirements ensuring client services are compliant as well as meet client expectations.
• Ensuring accuracy of claims processing and contract logic builds through internal audit processes
• Monitoring internal and external processes to detect any practices that, either directly or indirectly, result in fraud, abuse or waste that results in unnecessary costs.
• Running access queries as needed for administrative purposes.
• Assisting coworkers and contractual compliance auditors in additional compliance and auditing responsibilities.

WHAT YOU'LL NEED TO HAVE

• Minimum 3 years of experience in the healthcare or managed care industry, including claims/reimbursement experience, professional analytics-related experience and experience working on/managing major projects
• 1-3 years auditing experience in the healthcare industry
• Advanced to expert proficiency in the Microsoft Office products, especially Microsoft Word, Microsoft Excel & Microsoft Access
• Able to problem solve, exercise initiative, and make low to medium level decisions
• Thorough understanding of current federal, state and local healthcare compliance requirements
• Ability to meet deadlines and prioritize tasks; collect, correlate, and analyze data
• Ability to work independently with minimal supervision and as part of a team

WHAT WE WOULD LOVE FOR YOU TO HAVE

• Bachelor’s degree in healthcare informatics, business administration, or related field, or equivalent in experience and education
• Certified Professional Coder strongly recommended
• Prior claims processing experience within Eldorado HealthPac Claims Adjudication System is a plus
• Claim coding experience, coding edits experience and APC Pricing knowledge
• CPT and ICD coding knowledge

COMPENSATION

Guidehealth’s compensation structure includes more than just base salary. We believe in providing world-class benefits including comprehensive medical, dental, and vision plans, long and short-term disability, life insurance, and a 401k plan with a generous match. Our paid time off program includes paid holidays and flexible time that focuses on meeting the demands of the position and our clients, while providing the balance that our employees need.

The base pay range for this role is between $21.00 to $23.00 per hour, paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.

OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT

Diversity, inclusion, and belonging are at the core of Guidehealth’s values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race, religious creed, color, age, sex, sexual orientation and identity, national origin, citizenship, religion, marital status, familial status, physical, sensory, or medical disability, Family and Medical Leave, military or veteran status, pregnancy, childbirth or other related medical conditions, or any other classification protected by federal, state, and local laws and ordinances. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring, placement, promotion, transfer, demotion, layoff, termination, recruitment advertising, pay, and other forms of compensation, training, and general treatment during employment.

This position is responsible for following all Security policies and procedures in order to protect all PHI under Guidehealth’s custodianship as well as Guidehealth Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.