Lead Claims Auditor (QC)
Core
Conduct comprehensive professional and facility coding reviews (outpatient/professional and inpatient) to ensure code assignment accuracy, DRG/reimbursement correctness, and maximize overpayment identification.
Role type
Senior IC claims auditor (coding & reimbursement)
Builds
Accurate reimbursement solutions and overpayment recovery for health plans
Domain
US Healthcare Payer / Medical Coding & Reimbursement
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
CPC or CCS credential, expert ICD-10-CM/PCS guidelines, CPT/HCPCS coding, DRG encoder tools (3M, Webstrat), ambulatory surgery/ER/observation/infusion claims auditing, high-cost drug/DME auditing, CMS NCDs/LCDs familiarity
Preferred skills
RHIA or RHIT credential, start-up/high-growth environment experience, Mac proficiency
Technologies
3M, Webstrat, CMS NCDs/LCDs
Responsibilities
Conduct outpatient and professional coding reviews; Perform ambulatory surgery center, emergency room, observation, and infusion coding reviews; Utilize advanced DRG encoder tools to drive efficiency; Craft clear, supported audit findings based on AHA Coding Clinic Guidelines; Meet quality and productivity standards including appeal uphold rates; Stay ahead of coding updates and compliance regulations; Adhere to HIPAA and company policies.
Seniority
Senior, hands-on IC
