Medicaid Pre-Billing Auditor

Ablelight•Fresno, CA

17h•$90,000 - $100,000

About The Position

The Medicaid Pre-Billing Auditor independently evaluates Medicaid billing, coding, authorizations, service documentation, and related reimbursement practices to determine whether claims are accurate, properly coded, and compliant with federal and state requirements. A primary focus will be pre-billing audits. The role identifies billing risks, imposes billing holds before defective billing is initiated, recommends corrective actions, and monitors remediation to reduce regulatory risk. Limited reviews involving commercial payers may also be performed based on organizational need.

Requirements

Bachelor’s degree in healthcare administration, accounting or a related field; or an equivalent combination of relevant education and experience.
Minimum of five years of experience in auditing or a related function, including direct experience reviewing claims, coding, and supporting documentation for accuracy and regulatory compliance.
One of the following: Certified Professional Coder (CPC) through AAPC; or Certified Coding Specialist–Physician-based (CCS-P) through AHIMA; or Certified Professional Medical Auditor (CPMA); or Certified in Healthcare Compliance (CHC); or Another relevant healthcare coding, audit, compliance, or health information credential

Responsibilities

Conduct risk-based, prospective, and retrospective audits of Medicaid claims and records.
Determine whether documentation meets payer requirements. Impose internal billing holds where pre-billing audits find documentation does not meet billing standards.
Evaluate coding and billing accuracy using applicable CPT, HCPCS, ICD-10-CM, Medicaid program, waiver, managed-care, and state-specific requirements.
Support billing-related risk assessments, investigations, payer audits, government inquiries, and compliance reviews as assigned.
Promptly escalate suspected overpayments and other significant concerns in accordance with organization procedures.
Maintain complete and defensible audit reports documenting audit objectives, criteria, methodology, samples, evidence reviewed, exceptions, conclusions, and reviewer decisions.
Analyze findings to identify patterns, control weaknesses, potential financial exposure, and opportunities for process improvement.
Prepare concise written reports, dashboards, and presentations that communicate findings and recommended actions to Compliance leadership and appropriate stakeholders.
Recommend practical corrective actions and collaborate with accountable leaders to establish responsibilities, target dates, and validation measures.
Monitor corrective-action progress, perform follow-up testing, and determine whether remediation is effective and sustainable.
Maintain records of findings, corrective actions, management responses, and closure evidence.
Work collaboratively with various departments while preserving the objectivity of the Compliance audit function.
Help evaluate and implement audit-management platforms, compliance-monitoring software, analytics tools, dashboards, and automated exception-reporting capabilities.
Use approved data analytics and AI-assisted auditing technologies to analyze claims and documentation, identify outliers, prioritize higher-risk records, recognize recurring patterns, and expand audit coverage.
Serve as a subject-matter resource on Medicaid billing, coding, documentation, reimbursement, and audit requirements.
Monitor relevant Medicaid billing manuals, waiver requirements, regulatory updates, payer guidance, coding changes, and enforcement activity.
Identify education needs arising from audit results and provide content expertise to various departments.
Assist with the development or revision of organization policies and procedures.

Benefits

Medical, Dental, and Vision benefits starting the first of the month following 30 days of employment
Access to Teledoc
403(b) Retirement Savings Plan with 3.5% matching contributions
Health Savings Account
Flexible Savings Account
Basic Life, AD&D, STD, and LTD insurance
Paid Time Off (PTO)
Tuition Reimbursements
Training program will allow you to become CPR certified
Ongoing training to support Career Development
Any Day Pay with Dayforce Wallet