Itemized Bill Review Quality Auditor, Lead Associate- Remote (Any city, TX, US,

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

We are seeking a talented individual for a Lead Associate, Itemized Bill Review Quality Auditor to perform reviews of medical records, healthcare claims, itemized medical bill, and UB-04 forms to ensure accuracy, compliance, and proper billing practices. This role is responsible for conducting quality assurance audits and oversight of itemized bill review activities to ensure accuracy, consistency, regulatory compliance, and alignment with client-specific review methodologies. This role serves as a subject matter expert in hospital billing, reimbursement methodologies, payment integrity, and claim auditing.

The Lead Associate performs comprehensive quality reviews of itemized bill audits completed by clinical and coding review staff, validates audit findings, and provides regulatory and reimbursement support for determination decisions. This position requires extensive knowledge of hospital charging practices, revenue codes, UB-04 billing requirements, CMS reimbursement methodologies, NCCI edits, and payment integrity concepts. The individual is expected to identify opportunities for quality improvement, provide staff education and mentoring, and support the achievement of departmental quality and performance goals.

Your role in our mission

- Perform quality audits of itemized bill reviews to ensure accuracy, consistency, compliance, and proper documentation.

- Validate audit findings by reviewing itemized bills, medical records, claims, contracts, fee schedules, and supporting documentation.

- Evaluate billing errors, duplicate charges, unsupported services, coding, modifiers, units, reimbursement methods, and compliance requirements.

- Conduct complex audits of institutional claims, itemized bills, and medical records to identify inaccuracies, payment issues, and compliance concerns.

- Review inpatient, outpatient, emergency, ambulatory surgery, and ancillary service charges for billing and reimbursement accuracy.

- Assess revenue codes, charge capture practices, HCPCS, CPT, ICD-10 support, and payer requirements.

- Identify payment integrity opportunities through billing and reimbursement reviews.

- Serve as a subject matter expert in business proposals and assist with training, mentoring, and educating new reviewers.

- Maintain current clinical and coding knowledge and cross-train across multiple claim types to support client needs.

What we're looking for

- Associate degree in Health Information Management, Nursing, Healthcare Administration, Business Administration, or related healthcare field required.

- Certified Coder or Registered Nurse with Coding Experience. One of the following Coding Certifications preferred: RHIA, RHIT, CCS, CIC, CPMA, CCDS, COC or CPC

- Comprehensive knowledge of Revenue Codes, CPT, HCPCS, ICD-10 Coding Guidelines, Charge Master structure, UB-O4 billing requirements, APC, ASC, OPPS, DRG reimbursement methodology.

- Advanced knowledge of hospital billing practices, itemized bill review methodologies, and payment integrity concepts.

- Ability to interpret and apply payer contracts, billing regulations, and reimbursement guidelines.

- 3+ years Itemized Bill Review or Hospital Bill Audit experience required

- 3+ years of outpatient auditing experience with expert knowledge of ICD-10 Official Coding

- 3+ years medical record review experience or claims auditing preferred

- 5 years of healthcare billing, coding, pay