Clinical Itemized Bill Reviewer (RN, CPC)

Alaffia Health•,

10d

About The Position

Alaffia is seeking a Medical Bill Reviewer to review and analyze medical claims, patient medical records, and automated claim audit results, helping train the company’s machines to deliver automated audit results. The reviewer will perform high-dollar facility bill reviews and work alongside engineering teams to inform decisions about the future of healthcare claims auditing. The role requires current authorization to work in the United States; Alaffia is unable to sponsor work visas at this time.

Requirements

Facility inpatient coding or auditing experience is required.
A clinical license (RN) is required.
At least one of the following certifications is mandatory, or the candidate must be willing to obtain one within one year: CPC, CIC, CRC, or CPMA.
At least 3 years of auditing or bill review experience.
Experience performing audits on line-item charges on itemized bills.
Deep background in medical billing, coding, or auditing insurance claims and medical records.
Experience with national guidelines and code sets, including CPT, ICD-9/10, HCPCS, POS codes, DRGs, and APCs, and translating written clinical information into auditable clinical content.
Knowledge of hospital-based billing and coding.
Knowledge of PHI/HIPAA compliance and standards.
Ability to research and verify claim coding accuracy.
Current authorization to work in the United States; visa sponsorship is not available.

Nice To Haves

Experience working at an insurance company.

Responsibilities

Review UB-04 and itemized bills for potential coding and billing violations.
Compare itemized bills and UB-04s against medical records to validate charges and assess medical-record quality.
Audit revenue codes against clinical documentation.
Confirm that billed services were rendered.
Document inconsistencies between claims billed and health plan payments.
Confirm automated audit results against national and payer-specific guidelines.