Lead Claims Auditor (QC)

Das ist der Job

Self‑motivated, precision‑oriented, compliant, and continuous learner in a high‑growth environment.

Darum lohnt es sich

Opportunity Overview Lead Claims Auditor – Payment Integrity team. Passion for auditing and a commitment to teamwork, collaboration, and continuous learning. Familiarity with collaborating on a diverse, global team.

Conduct comprehensive professional and facility coding reviews (outpatient, professional, inpatient) to ensure accurate code assignment, DRG reimbursement, and identify overpayments. Must have CPC and/or CCS credential, expert knowledge of CPT, HCPCS, ICD‑10‑CM/PCS coding guidelines, and a passion for analytical auditing.

What you’ll do Conduct comprehensive coding reviews to ensure accuracy in code assignment and reimbursement across all claim types. Review ambulatory surgery center, emergency room, observation and infusion coding. Craft clear, concise audit findings backed by AHA Coding Clinic Guidelines and ICD‑10‑CM/PCS regulations.

Utilize advanced DRG encoder tools (e.g., 3M, Webstrat) to drive audit efficiency and accuracy. Meet or exceed company quality and productivity standards, including strong appeal uphold rates. Stay ahead of industry trends, coding updates, and compliance regulations to maintain expert‑level knowledge.

Adhere to HIPAA and company policies to ensure data security and regulatory compliance. Maintain and apply superior knowledge of coding guideline updates, reimbursement trends, and health payment policy language. Required Qualifications 8‑12 years of experience overall in coding or claims audit.

Expert‑level coding knowledge with deep understanding of ICD‑10‑CM/PCS guidelines and outpatient claims auditing. Ability to work independently in a remote environment while maintaining high performance. Exceptional time‑management, problem‑solving, and analytical skills.

Certification: CCS (Certified Coding Specialist) or CPC (Certified Professional Coder). Superior knowledge of HCPCS, CPT, ICD‑10‑CM/PCS coding, and U.S. healthcare payment methodologies across Commercial, Marketplace, Medicare, and Medicaid.

Experience auditing ambulatory surgery clinic claims and hospital observation claims, including injection and infusion claims. Experience auditing high‑cost drug and/or durable medical equipment claims. Bachelor’s degree completed. Excellent written and verbal English communication skills, strong analytical skills, and attention to detail.

Nice‑to‑haves Experience using CMS NCDs/LCDs and clinical criteria guidelines. RHIA or RHIT credential. Experience working in a start‑up or high‑growth company environment. Excellent computer skills and familiarity with a Mac. Equal Opportunity Statement Cohere Health is an Equal Opportunity Employer.

We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. #J-18808-Ljbffr