Health Plan Medical Claims Auditor - Possibility of Remote - PHOENIX

We are seeking a detail-oriented and experienced Medical Claims Auditor to join our team. As a Medical Claims Auditor, you will be responsible for reviewing and auditing medical claims to ensure accuracy, compliance with regulations, and adherence to company policies and procedures. You will work closely with the claims processing team to identify discrepancies, resolve issues, and improve overall claims accuracy.

Key Responsibilities

Conduct audits of medical claims to verify accuracy, completeness, and compliance with regulatory requirements.

Review claim documentation, including medical records and billing codes, to ensure proper coding and billing practices.

Identify errors, discrepancies, and potential fraud or abuse in claims submissions.

Investigate and resolve discrepancies through communication with internal departments, and clients.

Collaborate with the claims processing team to implement process improvements and ensure consistent adherence to company policies and procedures.

Prepare audit reports detailing findings, recommendations, and corrective actions taken.

Stay current with industry regulations, coding guidelines, and best practices related to medical claims processing and auditing.

Qualifications

Bachelor's degree or equivalent experience in healthcare administration, business administration, or a related field.

Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification preferred.

Minimum of 5 years of experience in medical claims processing, billing, or auditing.

Strong understanding of medical terminology, ICD-10, CPT, and HCPCS coding systems.

Knowledge of healthcare regulations, including HIPAA, Medicare, and Medicaid guidelines.

Excellent analytical and problem-solving skills with a keen attention to detail.

Effective communication skills, both verbal and written, with the ability to communicate complex information clearly and concisely.

Proficiency in Microsoft Office applications, especially Excel, and experience with claims processing software preferred.

COMPANY OVERVIEW

Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. Imagenet provides claims processing services, including digital transformation, claims adjudication and member and provider engagement services, acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with plans’ members and providers.

The company currently serves over 70 health plans, acting as a mission-critical partner to these plans in enhancing overall care, engagement and satisfaction with plans’ members and providers. The company processes millions of claims and multiples of related structured and unstructured data elements within these claims annually. The company has also developed an innovative workflow technology platform, JetStreamTM, to help with traceability, governance and automation of claims operations for its clients.

Imagenet is headquartered in Tampa, operates 10 regional offices throughout the U.S. and has a wholly owned global delivery center in the Philippines.

Imagenet LLC provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.