Lead Claims Auditor (QC)

Overview

Lead Claims Auditor on the Payment Integrity team, conducting professional and facility coding reviews across outpatient/professional and inpatient claims to ensure accurate code assignment, DRG/reimbursement, and overpayment identification.

What you'll do

• 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.
• Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications.
• Conduct ambulatory surgery center, emergency room, observation and infusion coding reviews.
• 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, 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 all information security activities implementation and maintenance process.
• Ensure the team is imparted with competence related to information security.
• Implement security policies and procedures and report any issues to the Information Security Manager.

What you'll need

• 8-12 years of experience overall.
• Expert-level coding knowledge with an in-depth understanding of ICD-10-CM/PCS coding guidelines.
• 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.
• In-depth knowledge of coding guidelines and industry-standard tools to identify and maximize potential overpayment recoveries.
• Exceptional time management, problem-solving, and analytical skills.
• Passion for auditing and a commitment to teamwork, collaboration, and continuous learning.
• Possess the CCS (Certified Coding Specialist) or CPC (Certified Professional Coder) credentials.
• Superior knowledge of HCPCS, CPT, ICD-10-CM/PCS coding, and US healthcare payment methodologies for Commercial, Marketplace, Medicare, and Medicaid.
• Completion of a bachelor's degree.
• Excellent written and verbal English communication skills, strong analytical skills, and attention to detail.

Nice to have

• Experience 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.
• Experience using CMS NCDs/LCDs and clinical criteria guidelines.
• RHIA or RHIT credential.
• Experience working in a start-up or high-growth company environment, demonstrating agility and adaptability.
• Familiarity with working with a diverse, global team of talent.
• Excellent computer skills and familiarity with a Mac.

Details

• Location: Nacharam, Hyderabad, Telangana; reliably commute or plan to relocate before starting work.
• Work in a remote environment.
• Interview process: Talent Acquisition, Hiring Manager, behavioral interview(s), case study interview with Senior Leadership (subject to change).