Lead Claims Auditor (QC)

About this role

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Skills you'll use

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.
• 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, 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.
• ISMS roles and responsibilities

Who can apply

• Maintain and apply superior knowledge of changes and updates to coding guidelines, reimbursement trends, and health payment policy language.
• Good knowledge of Information practices.
• Assist the manager in all the information security activities implementation and maintenance process.
• Ensuring the team and imparted with Competence related to Information security
• Responsible for the implementation of security policies and procedures and report any issues to the Information Security Manager.
• 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.

About Cohere Health

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