Lead Coding Auditor, Itemized Bill Review and Appeals- 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 Coding Auditor, Itemized Bill Review and Appeals who is responsible for performing itemized bill review, chart review, and coding validation to ensure that billed services were ordered, allowable, and accurately documented in the patient record; provide training to Coding Auditors; and perform all appeals related duties including participation in virtual and on-site hearings. The candidate must have extensive experience in inpatient hospital bill auditing, outpatient facility coding with charge master review.

Your role in our mission

- Verify that all lines on an itemized bill accurately reflect the services and procedures performed, are covered benefits, were appropriately ordered, properly documented, and reimbursed in accordance with plan policies and provider contract terms.

- Evaluate documentation to ensure accurate coding, charging, and reimbursement for inpatient hospital and outpatient facility services.

- Utilize proprietary auditing systems with a high level of proficiency to document audit findings and rationale.

- Reviews appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely.

- Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.

- Prepares case files and case summaries for hearings and actively participates in hearings virtually or on-site.

- Consistently achieve productivity and quality performance standards established by management.

- Actively cross-train to perform reviews of multiple claim types to provide a flexible workforce to meet client needs

- Assists management with training new Coding Auditors to include daily monitoring, mentoring, feedback and education.

- Maintains current knowledge of coding guidelines and successfully completes required CEUs to maintain coding certification.

- Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.

What we're looking for

- At least one of the following active professional credentials through AHIMA or AAPC: CPC, COC, CCS, RHIA, RHIT is required and maintained as a condition of employment

- 3+ years experience of inpatient hospital bill auditing, outpatient facility coding with charge master review; strongly preferred

- Working knowledge of the appeals and hearings process

- Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.

- Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions.

- Ability to multi-task in a fast-paced production environment.

- Demonstrated proficiency in medical record auditing and ICD-10 CM, ICD-10-PCS, APC, ASC, HCPCS, and CPT coding methodology.

- Strong working knowledge of hospital billing/charging including UB-04’s, itemized bills, revenue codes, CPT/HCPCS codes, ICD10 diagnosis and procedure codes

- Demonstrated proficiency in computer skills and typing, i.e., Microsoft Windows, Outlook, Excel, Word, PowerPoint, Internet browsers and in virtual meeting tools i.e., Microsoft Teams, Zoom, etc.

What you should expect in this role

- 100% Remote