Reconcile every submitted claim against EOBs, 835 remittance advices, and payment records to verify we received full and accurate reimbursement.
Audit PEPM payments against enrollment rosters, service logs, and LOA rate schedules across all MCP contracts.
Identify underpayments, denials, zero-pays, and systematic payment discrepancies—then drive resolution.
Prepare and file appeals for denied or underpaid claims with complete supporting documentation.
Cross-reference clinical documentation, care plans, and EHR records against claims to find unbilled and under-billed services.
Verify correct coding across HCPCS, CPT, and ICD-10—including CalAIM-specific ECM codes (G9007, G9008, G9012), CS codes and BH/SMHS codes.
Build and maintain audit dashboards tracking denial rates, days in A/R, collection rates, and payer-level variances.
Produce monthly revenue reconciliation reports for leadership with actionable findings.
Recommend and implement process improvements that prevent revenue leakage at the source.

3+ years in medical billing, claims auditing, or revenue cycle management in healthcare.
Hands-on experience auditing EOBs, reconciling payments, and managing denials and appeals.
Working knowledge of HCPCS, CPT, and ICD-10 coding.
Proficiency with EHR/billing systems and strong Excel or Sheets skills for data analysis.
Sharp analytical instincts and relentless attention to detail.
Bachelor’s degree in healthcare administration, HIM, business, accounting, or equivalent experience.

Billing Auditor

Key skills