Clinical Auditor

At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our purpose is simple - we strive to bend the cost curve in healthcare for all. Our dedication to service excellence extends to all our stakeholders – internal and external - driving us to consistently exceed expectations. We are intentionally bold, we foster innovation, we nurture accountability, we champion diversity, and empower each other to illuminate our collective potential. Be part of our amazing transformational journey as we optimize the opportunity towards becoming a leading technology, data, and innovation voice in healthcare. Onward and Upward!!! JOB SUMMARY: This role provides analysis of the highest dollar and most complex claims by applying research, coding standards, industry knowledge and federal regulations to ensure correct billing practices. In this role, incumbent will perform itemized bill reviews to identify billing abnormalities, unbundling, questionable billing practices and improper coding combinations from a clinical and coding perspective and documents denial reasoning or erroneous activity. JOB ROLES AND RESPONSIBILITIES: 1. Review and analyze complex inpatient and outpatient charges of various revenue centers with consideration to patient diagnosis, procedures, age and facility type including any additional information perceived as unbundled items and/or inappropriate charges. 2. Documents audit results and updates systems accordingly. Assist management in the daily operations and processes within the department. 3. Identify opportunities for recovery and avoidance. Researches opportunities to better control overpayments and presents ideas to management. 4. Drive successful coding operations through the application of learned, certified knowledge in addition to continuous professional development and ongoing coding research. 5. Provide general support to clinical team members, serving as a resource and subject matter expert (SME). 6. Monitors turnaround times for multiple applications and provides suggestions for process efficiencies. 7. Uses independent decision making skills to review claims after business hours to meet deadlines. 8. Apply national coding standards and regulations to claims billed. 9. Research and review individual claims, claim trends or detailed itemized bills, operative notes and other documentation as needed. 10. Monitor, research, and summarize trends, coding practices, and regulatory changes. 11. Apply clinical judgment and high level of expertise along with analytic skills in review of the most challenging and difficult cases; including conducting additional research as needed. 12. Communicates clinical, coding and reimbursement findings to co-workers and management in a clear, organized manner. 13. Partner with management to drive department goals and objectives 14. Collaborate, coordinate, and communicate across disciplines and departments. 15. Ensure compliance with HIPAA regulations and requirements. 16. Demonstrate Company's Core Competencies and values held within. 17. Please note due to the exposure of PHI sensitive data - this role is considered to be a High Risk Role. 18. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary. JOB SCOPE: This position works independently with minimal supervision in order to complete the outlined responsibilities. The incumbent balances several projects at a time and work is varied and complex. More complex issues are referred to higher levels. The incumbent follows established procedures and uses knowledge of the Company's general business principles, industry dynamics, market trends, and specific operational details when performing all aspects of the job. Apply tot his job Apply tot his job