住院及设施编码审计员 - 索赔审核专家（全职/远程）
Inpatient and Facility Coding Auditor - Claims Review Specialist (FT/REMOTE)
关于我们：
我们的目标是帮助客户实现其财务健康目标。在报销流程中，我们可扩展的解决方案和临床专业知识帮助解决程序性需求。通过领先的技术赋能我们的团队，使分析能够指导我们的解决方案，并确保我们达成目标。
我们通过投资于你来打造长期的职业生涯。我们致力于创造一个促进你职业发展和个人成长的环境，因为我们相信你的成功就是我们的成功。
职位概述：
理赔审核专员作为收入周期和编码顾问，与医疗信息主管合作，对医院住院、设施和门诊理赔进行复杂的实时和回顾性审计。该职位通过验证 ICD-10、CPT 和 HCPCS 代码分配是否符合 CMS、AHIMA、AHA 编码诊所和官方编码指南，评估编码准确性和文档合规性。使用专有软件，该专员分析理赔和编码数据，识别编码、计费和收入周期改进的机会，制定标准化报告，并向客户传达审计结果。该职位还提供编码教育，回答客户问题，准备书面指导和常见问题解答，支持客户会议，并与收入周期咨询团队协作，推动合规性、运营卓越和报销优化。
主要职责和责任：
注意：以下主要职责和责任旨在描述该职位的一般职责和责任，并非详尽的职责说明。该职位可能执行以下大部分或全部主要职责。具体任务、责任或能力可能根据直属领导团队规定的员工绩效目标进行记录。
工作职责：
- 分析发现的问题并识别产生的错误的根本原因。
- 为客户提供发现的总结报告，并提供支持报告中发现的具体参考资料。
- 对流程进行二级审核，以确保符合法律和程序政策，并确保适当的代码分配。
- 研究、分析并回应有关合规性、编码和拒付的查询。在所有情况下，保护患者健康信息和客户信息的隐私和机密性。
查看英文原文
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, CPCorRHIT 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.
Originally posted on Himalayas