Clinical Itemized Bill Reviewer (Appeals and Disputes)
RemoteUnited States or Manhattan, New York, United States
Job Summary
Review and investigate provider disputes related to Payment Integrity audit findings, focusing on high-dollar facility claims and itemized bills. Analyze UB-04s, medical records, clinical documentation, and coding information to validate charges, determine whether findings should be upheld, modified, or overturned, and develop clear, well-supported written responses. Compare itemized bills against clinical documentation to identify inconsistencies and apply relevant clinical, coding, and payer-specific guidelines. Manage a high-volume queue while maintaining accuracy, quality, and timely resolution, partnering with PIA Managers to ensure consistent decision-making. Clearly document case findings and rationale, identify recurring trends to improve audit processes, and maintain compliance with PHI/HIPAA requirements.
Required Qualifications
- Current authorization to work in the United States
- 3+ years of experience in Payment Integrity, medical bill review, clinical auditing, claims auditing, or a related healthcare claims function
- Hands-on experience reviewing and responding to provider appeals, disputes, reconsiderations, or challenges to Payment Integrity findings
- Strong experience performing itemized bill reviews and auditing facility claims, including UB-04s
- Deep knowledge of medical billing, coding, clinical documentation, and insurance claims
- Experience evaluating whether billed services and charges are supported by medical records and clinical documentation
- Strong understanding of relevant coding and reimbursement systems, including CPT, ICD-10, HCPCS, revenue codes, DRGs, APCs, and other applicable code sets
- Experience researching and applying national and/or payer-specific coding, billing, and reimbursement guidelines
- Ability to analyze complex clinical and claims information and translate findings into clear, defensible written responses
- Strong attention to detail and ability to manage a high-volume case queue while maintaining accuracy and quality
- Knowledge of PHI/HIPAA compliance and standards
- Strong written and verbal communication skills
- Ability to work collaboratively with Payment Integrity teams and PIA Managers
Desired Qualifications
- At least one of the following certifications is preferred: CPC, CIC, CRC, CPMA, or equivalent
- Active RN license preferred
- Experience working for a health plan, insurance company, or Payment Integrity organization preferred
- Experience with high-dollar facility bill review and complex claim auditing preferred
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