Lead Claims Auditor (QC)

Skills

About the Role

You will join a dynamic Payment Integrity team where you'll conduct comprehensive professional and facility coding reviews spanning outpatient/professional and inpatient claims. You'll apply your expert knowledge of CPT, HCPCS, and ICD-10-CM/PCS coding guidelines to ensure accurate code assignment and reimbursement, while maximizing overpayment identification. This role calls for a self-motivated professional who thrives on precision, compliance, and continuous learning in a fast-paced, high-growth environment.

Requirements

• 8-12 years of experience overall
• Expert-level coding knowledge with an in-depth understanding of ICD-10-CM/PCS coding guidelines and deep understanding of outpatient claims coding and auditing
• Self-motivated and able to work independently in a remote environment while maintaining high performance
• Expertise in outpatient and professional coding audits to ensure accurate code assignment and compliant reimbursement
• Exceptional time management, problem-solving, and analytical skills
• Passion for auditing and a commitment to teamwork, collaboration, and continuous learning
• CCS (Certified Coding Specialist) or CPC (Certified Professional Coder) credential
• Superior knowledge of HCPCS, CPT, ICD-10-CM/PCS coding, and US healthcare payment methodologies for Commercial, Marketplace, Medicare, and Medicaid
• Experience with coding ambulatory surgery clinic claims and hospital observation claims including injection and infusion claims
• Experience auditing high-cost drug and/or Durable Medical Equipment claims
• Completion of a bachelor's degree
• Excellent written and verbal English communication skills, strong analytical skills, and attention to detail

Responsibilities

• Conduct comprehensive coding reviews to ensure accuracy in code assignment and reimbursement
• Conduct comprehensive outpatient and professional coding reviews to ensure accuracy in code assignment and reimbursement
• Conduct ambulatory surgery center, emergency room, observation and infusion coding reviews
• Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications
• Craft clear, concise, and well-supported audit findings backed by AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations
• Utilize advanced DRG encoder tools such as 3M and Webstrat to drive efficiency and accuracy in audits
• Meet or exceed company quality and productivity standards, including strong uphold rates for appeals
• Stay ahead of industry trends, coding updates, and compliance regulations to maintain expert-level knowledge
• Adhere to HIPAA and company policies and procedures to ensure data security and regulatory compliance
• Maintain and apply superior knowledge of changes and updates to coding guidelines, reimbursement trends, and health payment policy language
• Assist the manager in information security activities implementation and maintenance process
• Ensure the team is imparted with competence related to information security
• Report any information security issues to the Information Security Manager