Claims Auditor
Core
Conduct comprehensive professional and facility coding reviews for outpatient and inpatient claims to ensure accurate code assignment, DRG/reimbursement, and maximize overpayment identification.
Role type
Senior Claims Auditor (Healthcare Coding & Payment Integrity)
Builds
Accurate reimbursement solutions and overpayment recovery for health plans
Domain
US Healthcare Payer / Medical Coding
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
CPC or CCS credential, expert knowledge of CPT/HCPCS/ICD-10-CM/PCS, DRG encoder tools (3M, Webstrat), HIPAA compliance, analytical auditing
Preferred skills
CMS NCDs/LCDs familiarity, RHIA/RHIT credential, high-cost drug/DME auditing experience, Mac proficiency
Technologies
3M, Webstrat, CMS NCDs/LCDs
Responsibilities
Conduct outpatient and professional coding reviews; Perform ambulatory surgery center, ER, observation, and infusion coding audits; Craft supported audit findings using AHA Coding Clinic Guidelines; Utilize advanced DRG encoder tools to drive efficiency; Maintain superior knowledge of coding guidelines and reimbursement trends; Adhere to HIPAA and company policies.
Seniority
Mid-Senior level (3-5 years experience)
