Sr. Clinical Auditor

Claritev•New York, NY

4d•$80,000 - $87,000•Remote

About The Position

The Senior Clinical Auditor analyzes high-dollar and highly 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 documenting findings and denial rationale. This role also serves as a subject matter expert supporting clinical review teams, operational efficiency, and coding education initiatives.

Requirements

High school diploma and 5+ years of line-item bill review experience, OR completion of required educational curriculum for a medical license or coding certification.
Extensive knowledge of inpatient and outpatient hospital billing, including:
UB-04 forms
Revenue codes
CPT codes
HCPCS codes
ICD-10 diagnoses and procedures
Strong medical knowledge to identify inappropriate or questionable charges.
Knowledge of DRG and APC reimbursement methodologies.
Familiarity with payer reimbursement policies, regulatory standards, and medical necessity criteria.
Experience reviewing medical records and claim documentation.
Strong analytical and problem-solving skills
Excellent communication and interpersonal abilities
Experience interpreting provider contracts and reimbursement policies
Proficiency with Microsoft Office (Excel, Outlook, PowerPoint); Visio a plus
Ability to manage multiple priorities in a fast-paced environment
Ability to mentor and educate team members

Nice To Haves

Bachelor’s degree in a related field.
Certified coding credential (CPC, CCS, RHIT, RHIA, or similar).
Experience in healthcare auditing or health information management.

Responsibilities

Review and analyze complex inpatient and outpatient charges across various revenue centers.
Evaluate charges based on patient diagnosis, procedures, age, facility type, and related documentation.
Perform detailed itemized bill reviews to identify unbundling, duplicate charges, improper coding combinations, and billing irregularities.
Apply national coding standards, federal regulations, and industry best practices to claims review.
Research and review claims, operative notes, claim trends, and itemized billing documentation.
Document audit results and update systems accordingly.
Ensure claim reviews comply with HIPAA regulations, reimbursement policies, and federal/state guidelines.
Monitor coding trends, regulatory updates, and industry practices impacting claim accuracy.
Apply clinical judgment and analytical expertise to review highly complex or escalated claims.
Identify opportunities for cost recovery and overpayment prevention.
Research and recommend improvements to reduce billing errors and increase operational efficiency.
Monitor turnaround times and recommend process enhancements.
Provide guidance to coders, negotiators, physicians, and internal teams on clinical and coding issues.
Participate in training, mentoring, and onboarding of new and existing staff.
Develop educational materials and job aids related to coding and claim review processes.
Support negotiation strategies by providing coding insights and claim review findings.
Partner with physician advisors, analytics teams, and leadership to enhance coding edits, claim factors, and reference materials.
Communicate coding, reimbursement, and clinical findings clearly to internal teams and leadership.
Collaborate across departments to support departmental and organizational goals.
Assist management with operational support and departmental initiatives.
Evaluate performance of new and existing team members when applicable.
Demonstrate commitment to company values and organizational objectives.
Due to exposure to Protected Health Information (PHI), this role is classified as a High Risk Role.
Perform additional duties as assigned.