Clinical Auditor
About The Position
At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our mission is simple: to bend the cost curve in healthcare for all. Our commitment to service excellence extends to both internal and external stakeholders, driving us to consistently exceed expectations. We operate with intention and purpose—fostering innovation, championing diversity, nurturing accountability, and empowering each other to reach our collective potential. Join us as we continue our transformational journey to become a leading voice in healthcare technology, data, and innovation. The Clinical Auditor analyzes high-dollar and complex healthcare claims to ensure accurate billing practices and regulatory compliance. In this role, you will apply advanced clinical knowledge, coding standards, industry expertise, and federal regulations to review itemized hospital bills and claim documentation. You will identify billing abnormalities, unbundling, questionable billing practices, and improper coding combinations while clearly documenting audit findings and denial rationale.
Requirements
- Bachelor’s degree preferred or equivalent experience
- Minimum 5+ years of experience in medical coding, auditing, reimbursement, or claims review
- Strong knowledge of inpatient and outpatient hospital billing including UB-04s, revenue codes, CPT, HCPCS, and ICD-10 coding
- Knowledge of payer reimbursement policies, federal/state regulations, and medical necessity criteria
- Experience reviewing itemized bills and identifying billing discrepancies
- Ability to read and interpret medical records, including operative notes and clinical documentation
- Strong analytical, problem-solving, and critical thinking skills
- Excellent communication and interpersonal skills
- Proficiency in Microsoft Office (Excel, Outlook, PowerPoint)
- Ability to manage multiple priorities in a fast-paced environment
- Ability to work flexible hours, including evenings or weekends as needed
Nice To Haves
- Coding certification (CPC, CCS, RHIT, RHIA)
- Experience in auditing or health information management
- Experience with facility contract interpretation
- Clinical or direct patient care background
- Experience mentoring or training team members
Responsibilities
- Review and analyze complex inpatient and outpatient claims across multiple revenue centers, considering diagnosis, procedures, patient demographics, and facility type
- Perform detailed itemized bill reviews to identify unbundling, duplicate charges, and billing irregularities
- Apply national coding standards, payer policies, and federal/state regulations to claims review
- Document audit findings, denial rationale, and system updates with accuracy and clarity
- Research claims, trends, operative notes, and supporting documentation to support audit decisions
- Identify opportunities for cost recovery and overpayment prevention; present findings to leadership
- Monitor coding trends, regulatory updates, and industry practices impacting claim accuracy
- Apply clinical judgment and analytical expertise to review highly complex or escalated cases
- Communicate audit findings and reimbursement insights clearly to internal stakeholders and leadership
- Serve as a subject matter expert (SME) and resource to clinical and operational teams
- Collaborate cross-functionally to support departmental goals and process improvements
- Monitor turnaround times and recommend workflow efficiencies
- Support development of educational materials, job aids, and training resources
- Ensure compliance with HIPAA and all applicable regulatory requirements
- Demonstrate company core competencies and contribute to a culture of accountability and excellence
Benefits
- Medical, dental and vision coverage with low deductible & copay
- Life insurance
- Short and long-term disability
- Paid Parental Leave
- 401(k) + match
- Employee Stock Purchase Plan
- Generous Paid Time Off – accrued based on years of service
- WA Candidates: the accrual rate is 4.61 hours every other week for the first two years of tenure before increasing with additional years of service
- 10 paid company holidays
- Tuition reimbursement
- Flexible Spending Account
- Employee Assistance Program
- Sick time benefits – for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year, unless the laws of the state in which the employee is located provide for more generous sick time benefits
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
