Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development.
Summary
We are seeking a talented individual who is responsible for full claim overpayment analysis. Assists with identification of claims paid in error and audits paid claims data through multiple tools and methods by utilizing state and federal manuals/regulations, billing and reimbursement policies and practices as well as identifying changes in system edits or new system edits.
Your role in our mission
- Analyze healthcare claims using CMS, state, client, and payer reimbursement policies, regulations, and billing guidelines to identify overpayments and recovery opportunities with minimal supervision.
- Review paid claims and member eligibility data to identify overpayment trends, patterns, and potential audit opportunities.
- Collaborate with data analysts, clinical teams, IT resources, and business stakeholders to identify, validate, and recover overpaid claims.
- Maintain accurate audit documentation, track findings, and effectively communicate results to internal and external stakeholders.
- Consistently achieve individual and team performance goals while supporting departmental objectives.
- Recommend and implement enhancements to existing audit processes, methodologies, and data queries to improve efficiency and outcomes.
- Partner with internal teams to research provider billing practices, claims processing trends, and reimbursement policies to uncover new recovery opportunities.
- Assist in developing and evaluating new audit concepts and payment integrity initiatives.
- Prepare supporting documentation, sample claims, and audit approval materials required for client review and implementation of new audit concepts.
- Research and apply industry standards, clinical guidelines, and regulatory requirements to support audit activities.
- Monitor recovery efforts and follow through to resolution.
- Prepare reports, metrics, and tracking tools to support team performance and operational objectives.
- Demonstrate strong analytical, organizational, verbal, and written communication skills while working collaboratively in a team-oriented environment.
What we're looking for
- High school diploma or GED required; bachelor’s degree preferred
- 4-6 years of healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, and/or revenue cycle improvement required
- Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-9-CM codes, HCPCS codes, CPT codes, DRGs, physician billing, etc.
- Experience in healthcare auditing, reviewing and validating the accuracy of claims data and accuracy of claims payment preferred
- Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data, Recovery audit experience a plus preferred
What you should expect in this role
- Fully remote work environment.
- Opportunity to support healthcare payment accuracy and program integrity initiatives.
- Collaborative team culture focused on innovation, continuous improvement, and professional growth.
The pay range for this position is $34,300.00 - $49,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.
Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
