Clinical Itemized Bill Reviewer (Appeals and Disputes)

Alaffia Health•,

About The Position

Alaffia is seeking a Clinical Itemized Bill Reviewer to join their Appeals and Disputes team. This role focuses on reviewing and investigating provider disputes related to Payment Integrity findings, with an emphasis on high-dollar facility claims and itemized bills. The reviewer will analyze various documents including itemized bills, UB-04 claim forms, medical records, clinical documentation, and coding information to determine the validity of disputed findings. This position is ideal for individuals with prior experience in Payment Integrity, medical bill review, and provider appeals or disputes, utilizing their clinical, coding, and auditing skills to provide well-supported responses to providers. The role involves close collaboration with the Payment Integrity team and PIA Managers to ensure accurate and consistent outcomes in a high-volume environment.

Requirements

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
Current authorization to work in the United States

Nice To Haves

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

Responsibilities

Review and investigate provider disputes related to Payment Integrity audit findings
Review high-dollar facility claims and itemized bills for potential coding, billing, and payment inaccuracies
Analyze original audit findings, UB-04s, itemized bills, medical records, clinical documentation, and supporting provider materials
Compare itemized bills and claim forms against medical records and clinical documentation to validate charges and assess the accuracy of billed services
Determine whether Payment Integrity findings should be upheld, modified, or overturned based on available evidence
Research and apply relevant clinical, coding, billing, national, and payer-specific guidelines
Develop clear, accurate, and well-supported written responses to provider disputes
Identify inconsistencies between claims billed, clinical documentation, coding, and health plan payments
Validate coding, billing, and clinical findings using applicable code sets and reimbursement guidelines
Clearly document case findings, rationale, and final determinations
Manage a high-volume queue of provider disputes while maintaining accuracy, quality, and timely resolution
Partner closely with PIA Managers and other Payment Integrity team members to review complex cases and ensure consistent decision-making
Identify trends and recurring issues across provider disputes and share insights that can improve Payment Integrity audit processes
Maintain compliance with PHI/HIPAA requirements and applicable healthcare regulations and standards