State Licensed Medical Claims Auditor

Job Summary

To support a growing Special Investigations Unit, the remote State Licensed Medical Claims Auditor will review claims for billing and coding-related issues, leverage AI tools to identify anomalous billing patterns, and collaborate with cross-functional teams to enhance the effectiveness of the fraud, waste, and abuse audit program.

Key responsibilities

• Review claims for billing and coding-related issues to prevent inaccurate payments and disrupt fraud, waste, and abuse
• Utilize internal AI tools to identify billing anomalies and support targeted prepayment audits
• Collaborate with Data Science and Engineering teams to validate AI-flagged claims and provide expert coding feedback

Required qualifications

• 3+ years of coding and auditing experience, with CMS regulations preferred
• Certified Professional Coder (CPC) certification
• Strong knowledge of National Rules of Correct Codification defined by CMS
• Experience in a technology environment, including claims systems and workflow management tools
• Prior experience in health insurance, with Medicare Advantage experience as a plus