Description: • Conduct routine monitoring and audits of procedures, including but not limited to billing systems audits, Encounter submission audits, and client audits. • Understand and stay current with client contract criteria and requirements ensuring client services are compliant as well as meet client expectations. • Generate and submit all required Commercial claims reporting. • Play a vital role in preparing for the annual Health Plan audits. • Confirm pricing is correct in the fee tables after the downloads are complete. • Monitor internal and external processes to detect any practices that, either directly or indirectly, result in fraud, abuse or waste that results in unnecessary costs. • Participate in auditing and submitting appeals and UM Challenges for Reinsurance process. • Run access queries and impact reports as needed for administrative purposes. • Assist coworkers and Internal Auditors in additional compliance and auditing responsibilities, including pre-payment and post-payment audits. • Consistently exercise independent judgment and discretion in matters of significance. • Other duties and responsibilities as assigned. Requirements: • Minimum 3-5 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. • Minimum 3 years auditing experience in the healthcare industry. • CPT and ICD coding knowledge. • Knowledge of Medicare requirements and APC Pricing knowledge. • Advanced to expert proficiency in the Microsoft Office products, especially Microsoft Word, Microsoft Excel & Microsoft Access. • Successfully function as an Internal Claims Auditor. • Able to problem solve, exercise initiative and make medium to high 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. • Must be organized, self-motivated, detail-oriented, disciplined, professional, and a team player. • Effective written and oral communication. • 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. Benefits: • Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs. • Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered. • Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution. • Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected. • Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times. • Take Time for Yourself: We offer Flexible Time Off tailored to meet your needs and the needs of the business, helping you achieve work-life balance and meet your personal goals. • Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need. • Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us. Apply Job!