Medical Claims Reviewer

NOW HIRING: Medical Claims Reviewer Location: Harrisburg, PA (Hybrid – 2 Days Onsite / 3 Days Remote) Pay Rate: $19.00/hour Schedule: Monday – Friday, 8:00 AM – 4:00 PM

Overview

A-Line Staffing is seeking a detail-oriented Medical Claims Reviewer to join a healthcare compliance team responsible for reviewing medical records and claims to ensure services provided to Medicaid recipients are properly documented, medically necessary, and billed correctly. This role is ideal for candidates with experience in healthcare administration, medical records, utilization review, medical billing, coding, claims review, quality assurance, or healthcare compliance.

Key Responsibilities

• Review medical records and healthcare claims to verify services were appropriately documented and billed.
• Ensure medical services meet Medicaid guidelines and medical necessity requirements.
• Identify potential billing discrepancies, including duplicate billing, incorrect coding, upcoding, and unbundling of services.
• Analyze claims data and provider billing patterns for compliance concerns.
• Research and review provider documentation to ensure compliance with State and Federal regulations.
• Prepare written findings, reports, summaries, and provider correspondence.
• Maintain accurate case records and update tracking systems throughout the review process.
• Collaborate with nurse reviewers, physicians, legal counsel, and other healthcare professionals regarding case findings.
• Participate in meetings and discussions related to provider reviews and compliance investigations.
• Assist with researching and responding to complaints received from providers, members, and other sources.

Qualifications

• Associate's Degree in Health Services Management or a related healthcare field OR
• Minimum of 2 years of experience in healthcare administration, medical records, claims review, utilization review, healthcare compliance, medical billing, coding, or a related healthcare role.
• Experience reviewing medical records and healthcare documentation preferred.
• Knowledge of ICD-10, CPT, HCPCS coding, medical billing, or healthcare compliance is a plus.
• Proficiency with Microsoft Office and electronic healthcare systems.

Why Apply? This position offers the opportunity to make a meaningful impact by helping ensure healthcare providers deliver quality care, maintain proper documentation, and bill accurately while protecting the integrity of the Medicaid program. Interested candidates should be comfortable working in a hybrid environment and able to report onsite in Harrisburg, PA two days per week. Contact: Alliston Brown | 586-710-7944 | [email protected]