Certified Medical Auditor – Claims Review

About Us All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick, birthday, and vacation time as well as a 410k matching plan. Additional employee paid coverage options available. Job Purpose The Certified Medical Auditor – Claims Review supports the Managed Service Organization (MSO) by performing detailed medical claims reviews to ensure accuracy, compliance, and appropriate reimbursement across Medicare, Commercial, and Medicaid lines of business. This role focuses on validating diagnosis and procedure coding, identifying improper billing or documentation, and supporting medical necessity determinations in alignment with CMS and payer-specific guidelines. The coder serves as a key liaison between care management and claims operations to promote coding accuracy and support efficient payment processes within value-based care arrangements. Duties and responsibilities • Review provider medical records to validate the following claim data: • Codes billed are accurate, complete, and comply with MSO and payer policies • Codes billed comply with bundling and unbundling guidelines and global period policies • ICD-10 codes are chosen appropriately and to the highest level of specificity • CPT and HCPCS codes accurately report the services rendered including level of E&M code in accordance with AMA, CMS, and state-specific coding standards • Documentation supports billed services under Medicare, Medicaid, and Commercial payer rules. • Identify and report potential coding errors, documentation gaps, or billing inconsistencies that impact reimbursement or compliance. • Collaborate with nurses, medical director, and claims teams to adjudicate/deny claims with coding and/or documentation errors • Support retrospective and prospective reviews to improve claims accuracy and reduce preventable denials. • Participate in internal audits, education sessions, and process improvement initiatives to enhance coding integrity. • Stay current on updates to CMS regulations, payer billing policies, and industry coding changes. • Protect member and provide confidentiality by adhering to HIPAA and MSO compliance standards. Qualifications • Certification: Current CPC, CCS, or CCA credential from AAPC or AHIMA (required). • Experience: Minimum 3 years of professional and facility coding experience, including claim review within a Managed Service Organization, health plan, or large provider network. • Demonstrated knowledge of Medicare, Commercial, and Medicaid coding, billing, and reimbursement requirements. • Familiarity with risk adjustment and value-based care models preferred. • Proficient with EHR and claims management systems (e.g., Epic, Cerner, IDX, or payer portals). • Strong knowledge of medical terminology, anatomy, physiology, and healthcare regulations. • Experience with utilization management, claims auditing, and payment integrity programs. • Working knowledge of MCG, InterQual, and CMS National Coverage Determinations (NCDs)/Local Coverage Determinations (LCDs). • Working knowledge of DRG • Prior experience collaborating with provider groups in an MSO or IPA environment. Apply tot his job Apply tot his job