About Us:
Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals.
We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.
JOB SUMMARY:
The Claim Review Specialist serves as a revenue cycle and coding consultant, partnering with the Director of HIM to perform complex concurrent and retrospective audits of hospital inpatient, facility and outpatient claims. This role evaluates coding accuracy and documentation compliance by validating ICD-10, CPT, and HCPCS code assignments in accordance with CMS, AHIMA, AHA Coding Clinic, and official coding guidelines. Using proprietary software, the specialist analyzes claim and coding data, identifies opportunities for coding, billing, and revenue cycle improvement, develops standardized reports, and communicates audit findings to clients. The position also provides coding education, answers client questions, prepares written guidance and FAQs, supports client meetings, and collaborates with the revenue cycle consulting team to drive compliance, operational excellence, and reimbursement optimization.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.
Job Responsibilities:
- Analyze findings and identify potential root causes of produced errors.
- Prepare summary reports of findings to clients, supplying specific references supporting findings contained within the provided audit report.
- Provides second-level review of processes to ensure compliance with legal and procedural policies and to ensure appropriate code assignments.
- Research, analyze, and respond to inquiries regarding compliance, coding, and denials. In all situations, protect the privacy and confidentiality of patient health and client information, and follow the
- Standards of Ethical Coding as set forth by AHIMA and adhere to official coding guidelines and compliance practices, standards, and procedures.
- Functions as a member of the Consulting Services Team which develop and provide coding education to clients.
- Conduct Audits as assigned meeting the productivity standards as set by record type for each audit. The threshold for billable productive hours, when client work is available, is expected to be at or above 80%.
- Prepare deliverables for the client as required for the audit scope while meeting timelines.
- Conduct independent QA of their assigned audit results prior to final submission for QA review and approval. The minimum accuracy expectation is 95%.
- Report work time and work products in a timely and accurate manner.
- Communicates with coworkers in an open and respectful manner that promotes teamwork and knowledge sharing.
- Interact with clients in a professional manner that, always, exhibits excellent relationships, work performance and communication skills so as to support the company and its business interests.
- Provide schedule of planned work activities, events and sites, and any changes to same, to Management and appropriate staff.
- Maintenance of professional credentials and knowledge of coding, reimbursement, and compliance issues through continuing education.
- Periodic travel, as applicable.
- Other duties and responsibilities, as assigned.
Knowledge Skills and Abilities:
- Active AHIMA or AAPC credential required; CCS, CPC or RHIT required
- Minimum of five (5) years of coding and/or auditing experience in an acute care hospital or healthcare consulting environment, including inpatient and facility services.
- Strong knowledge of ICD-10-CM/PCS, CPT, HCPCS, reimbursement methodologies, regulatory compliance, and audit best practices.
- Proficiency with electronic health record (EHR) systems, such as Epic, Cerner/PowerChart, Meditech, and other healthcare applications.
- Advanced analytical, critical-thinking, and problem-solving skills with the ability to interpret complex clinical, coding, and regulatory information.
- Strong computer skills, including proficiency in Microsoft Office applications and auditing/reporting software.
- Excellent written and verbal communication skills with the ability to present findings and provide clear, client-focused guidance to both operational and executive audiences.
- Demonstrated ability to manage multiple projects, client engagements, and priorities while working independently with minimal supervision.
- Highly organized with strong attention to detail, accuracy, and commitment to ethical coding and auditing practices.
- Experience working remotely and collaborating effectively within a team-oriented, consulting-focused environment.
- Ability to work successfully with multiple clients, diverse stakeholders, and cross-functional teams while maintaining productivity and quality standards.
We Offer:
- Quality of life with a remote predictable, full-time schedule
- Competitive Salary commensurate to experience
- Medical, Dental, Vision coverage and more
- Long-term disability insurance, and life insurance
- Ample parental leave
- 401K with company match
- Certification and Tuition Reimbursement
- Holidays, Flexible Time Off
PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.
