Healthcare Audit and Appeals Specialist

Job Description

Job Description

Job Summary:

Healthcare Audit and Appeals Specialist supports the organization in responding to government healthcare audits related to Medicare and Medicaid billing. This role ensures documentation and billing records meet regulatory requirements and assists with preparing audit responses for government agencies and contractors. The specialist serves as a key point of contact for audit communications and helps maintain compliance with Centers for Medicare & Medicaid Services (CMS) regulations.

Key Responsibilities:

• Coordinate responses to government audits involving Medicare and Medicaid claims.
• Collect, review, and submit medical records and billing documentation requested by auditors.
• Process audit-related correspondence, including incoming and outgoing mail and electronic communications.
• Maintain accurate records of audit activity, documentation submissions, and deadlines.
• Assist with preparation of audit responses and appeals when claims are questioned or denied.
• Communicate with government contractors and regulatory agencies regarding audit requests and follow-up actions.
• Ensure compliance with CMS regulations, privacy laws, and healthcare documentation standards.
• Enter and manage audit data in internal tracking systems and reports.

Required Qualifications:

• Minimum 3 years of Medicare billing experience, preferably in an acute care hospital setting.
• 1–3 years of experience with healthcare audits or regulatory compliance.
• Knowledge of CMS billing rules, reimbursement methodologies, and documentation requirements.
• Understanding of HIPAA privacy regulations and information release procedures.
• Ability to manage multiple projects and meet strict audit deadlines.
• Proficiency with Microsoft Office (Word, Excel, PowerPoint, Outlook).

Preferred Skills:

• Experience working with government audit programs such as RAC, MAC, TPE, CERT, OIG, or QIO.
• Strong attention to detail and organizational skills.
• Effective written and verbal communication skills.
• Ability to work independently and collaborate with compliance, billing, and clinical teams.