Clinical Policy Specialist - Itemized Bill Review (Remote)

Gainwell Technologies LLC•Any city, OH

49d•$86,800 - $115,000•Remote

About The Position

The Clinical Policy Specialist – Itemized Bill Review is responsible for the development, enhancement, and performance of Itemized Bill Review clinical and coding solutions. This role serves as the primary subject matter expert for Itemized Bill Review policies, methodologies, and audit strategies, leveraging expertise in healthcare reimbursement, facility billing, revenue integrity, coding, payment policies, and regulatory requirements. The ideal candidate will possess extensive knowledge of inpatient and outpatient facility billing, UB-04 claim processing, itemized bill analysis, coding guidelines, reimbursement methodologies, and payment integrity strategies. This role is responsible for developing and maintaining audit concepts, conducting clinical and coding research, analyzing claims and billing data, monitoring program performance, supporting client implementations, and ensuring content aligns with industry standards and regulatory requirements. This position plays a critical role in identifying billing vulnerabilities, developing innovative audit strategies, improving claim selection methodologies, and maximizing recovery opportunities while ensuring accurate and defensible review outcomes.

Requirements

Associate’s Degree required, Bachelor's degree preferred (health administration, business, nursing)
Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
At least one of the following coding certifications RHIA, RHIT, CCS, CCS-P, CIC, CPC, CPMA or equivalent clinical/coding credential.
5+ years of experience in payment integrity, healthcare reimbursement, facility claims auditing, medical bill review, DRG validation, revenue integrity, or clinical policy development.
5+ years of experience performing Itemized Bill Review or Medical Bill Review auditing facility claims.
3+ years of experience with healthcare policy, Medicare guidelines and State regulation research and interpretation.
Extensive knowledge of Medicare and Medicaid reimbursement methodologies, hospital billing practices, UB-04 claims, coding guidelines, and revenue cycle processes.
Experience developing audit concepts, review criteria, policies, or payment integrity solutions.
Ability to research State and Federal regulations, clinical policies, coding guidelines to develop and implement policies, clinical/coding resources, and tools to support Gainwell’s Clinical Claim Review products.

Responsibilities

Collaborate with cross-functional teams to develop clinical and coding solutions, audit strategies, Itemized Bill Review policies, and payment integrity initiatives.
Design audit focused on billing accuracy, reimbursement validation, charge capture integrity, and payment integrity opportunities.
Develop clinical and coding review criteria to identify billing discrepancies and recovery opportunities.
Use data analysis and research to develop new clinical and coding concepts, targets, edits, and Itemized Bill Review solutions.
Monitor performance, present results to leadership, and recommend improvements.
Support the review of clinical and coding solutions.
Work with analytics, operations, product, and audit teams to bring clinical and coding concepts from development to implementation.
Monitor regulatory and coding guideline changes and adjust rules and programs as needed.
Serve as the SME for Itemized Bill Review policies, reimbursement methodologies, facility billing practices, and audit standards.
Research Medicare, Medicaid, commercial payer, state-specific, and facility billing requirements.
Develop audit rationales and supporting documentation for findings and recoveries.
Assist with research, special projects, and ad hoc claim reviews.
Develop clinical and coding content, training, and education to support Clinical Services, Quality, and Appeals teams.
Maintain expertise in clinical and coding programs and provide SME support to account management, sales, clients, and clinical teams.
RFP support and work directly with clients to explain programs, address concerns, and develop proactive solutions.