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Medical Claims Auditor (CPC) - (AssociatesMD)

Bright Health

Bright Health

Plantation, FL, USA
Posted on Tuesday, November 29, 2022

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Our mission is to make healthcare right. Together. We are a value-driven healthcare company committed to providing personalized care to aging and underserved populations. We do this by aligning stakeholders across the healthcare ecosystem. Together, we can improve consumer experience, optimize clinical outcomes, and reduce total cost of care.

What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.

If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.

We are seeking a Medical Claims Auditor to join our Revenue Cycle team. The Medical Claims Auditor reviews the services provided and compares them to EHR and billing records to determine accuracy and is responsible for performing quality reviews of outpatient medical records to validate the integrity of ICD9/ICD-10 diagnoses and procedures as well as CPT/CPT II coded procedures. This role is also responsible for ensuring that billing is optimized, and errors are minimized by identifying opportunities through audit and observation. The Medical Coder/Auditor remains abreast of regulatory and procedure changes which may affect coding compliance and /or reimbursement.


  • Review medical records and other documentation to identify under and over-coded services, prepares reports of findings, and meets with management to educate on and improve coding practices.
  • Ensure appropriate coding and maintain compliance documentation.
  • Determines priorities and methods of completing daily workload to ensure that all responsibilities are carried out promptly.
  • Performs all job functions professionally and courteously. This includes answering all general phone calls timely and providing excellent customer service to internal and external customers.
  • Reviews and researches billed unlisted procedure codes to determine if a more specific code exists and should be used.
  • Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies as necessary or required.
  • Fosters and promotes a culture of service excellence and accountability.
  • Effectively communicates with providers to clarify diagnoses, procedure coding, and documentation requirements, including proper sequencing.
  • Reviews assigned ICD-9-CM / ICD-10-CM codes, which most accurately describe each documented diagnosis and/ or procedure according to established ICD-9-CM / ICD-10-CM and CPT-4 coding guidelines along with modifier usage and medical terminology.
  • Monitors all coding accuracy at various levels of detail and maintains coding quality as needed.
  • Tracks coding issues and reviews coding inaccuracies to highlight areas of improvement. Reports or resolves escalated issues as necessary.
  • Performs a comprehensive medical records review to assure the presence of all parts including patient and record identification signatures, dates where required, and other necessary data in the presence of all reports which appear to be indicated by the nature of the treatment rendered.
  • Monitors, audits, and reconciles all documents required for data entry, and returns incomplete or questionable documents to generating location or provider.
  • Provides a high technical education and serves as a subject matter specialist in coding and documentation.
  • Supports and educates team members about coding best practices and procedures to meet compliance and regulatory requirements.
  • Reviews payment denials, underpayments, and payment takebacks for appropriateness and guides resolution by resubmission to the insurance carrier, patient billing, or appropriate adjustment.
  • Collaborates with interdepartmental or cross-functional teams for assigned projects and provides departments with coding issues and updates to be shared with providers to ensure timely and accurate claim payment.
  • Utilizes audit results to provide data-driven feedback to providers and management to improve coding accuracy and identify opportunities for improvement and re-training.
  • Ensures and monitors completion and accuracy of all encounter forms for all new and continuing patients.
  • Assists business services with the maintenance of data files necessary to perform tasks.
  • Complies with organizational policies and procedures.


  • Associates degree or equivalent
  • Three years as a Certified Professional Coder (CPC) with billing office experience required.
  • Must clearly understand medical terminology, Current Procedural Terminology (CPT), and International Classification of Disease (ICD) coding in Medicare and outpatient coding.
  • Working knowledge of billing for a multi-discipline practice and general computer systems required.
  • Ability to read and interpret documents, such as policies and procedures, benefits information, benefit surveys, board minutes, routine mail, simple contracts, and procedure manuals.


  • Must be comfortable educating providers.
  • Organizes and prioritizes work with minimum supervision.
  • Performs most essential job duties independently and exercises good judgment.
  • Demonstrates initiative and creativity in assigned work while constantly attempting to improve workflows.
  • Demonstrates ability and flexibility to work in other areas of the organization as needed.

We offer comprehensive employee benefits that include medical/dental/vision coverage, 401(K) plan, an HSA, an Employee Assistance Program and annual Paid Time Off along with 8 paid company holidays.

As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of Bright Health, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.