Description
Essential Job Functions
- Pull medical record (H&P, op notes, anesthesia record, MAR, nursing notes, implant logs, pathology, radiology) and itemized bill / UB-04 / 1500 detail and reconcile line by line against billed charges.
- Validate CPT / HCPCS / ICD-10-CM / revenue code / modifier / units / DOS against documentation; flag overcharges, undercharges, missing charges, and inappropriate bundling / unbundling.
- Apply NCCI PTP, MUE, OCE, and LCD / NCD logic; document defensibility of each line decision.
- Defend billed charges against payor / payor-vendor audit findings (Equian / Optum Payment Integrity / Cotiviti / Zelis / SCIO / others).
- Build a structured rebuttal with citations (CMS NCCI manuals, AMA CPT guidelines, payor policy, AHA Coding Clinic, contract language as applicable).
- Negotiate with audit vendors within delegated authority; escalate to Lead when concession would exceed threshold.
- Review patient billing disputes raised through customer service / Patient Financial Services intake.
- Reconcile disputed line items against medical record and applicable EOB; produce a patient-readable explanation.
- Escalate suspected billing errors for write-off / adjustment per client policy.
- Maintain a real-time individual case log (tracking status, turnaround time, $ impact, and outcomes) using standardized taxonomies to support portfolio trend analysis.
- Produce reproducible, structured audit reports using standard templates to communicate scope, methodology, line-level results, and root causes to client stakeholders and feed activity reports.
- Navigate provider EHR platforms (e.g., Epic, Cerner, Meditech) and specialized auditing software to abstract clinical documentation and support defense workflows.
- Operate under HIPAA, HITRUST, and OIG / RAC / MAC awareness; never share PHI outside authorized channels.
- Cooperate fully with internal QA on sample audits; respond to QA findings with documented corrective action.
Key Success Indicators/Attributes
- High comfort level reading dense clinical records (MAR, operative notes, nursing logs) and cross-referencing against itemized bills to identify root causes.
- Confidence and technical writing skills to draft clear audit findings and defend them during payor rebuttal cycles, with the objectivity to overturn findings when evidence shifts.
- Clear understanding of how line-item charge adjustments impact gross/net revenue, DRG allowances, and patient billing integrity.
- Consistently meets daily turnaround time (TAT) targets without compromising audit accuracy.
- Sustained concentration and analytical rigor required to execute multi-hour reviews on complex inpatient, surgical, and high-dollar cases.
- Confidentiality and PHI discipline.
- Maintain courteous and professional working relationships with employees at all levels of the organization.
Qualifications
This is a full-time position.
- Each employee’s schedule must be between the hours of 6:00 AM PST to 9 PM PST, Monday through Friday with the specific schedule for each employee to be agreed upon by the employee’s manager and the employee, taking into account the needs of the client.
- This position occasionally requires long hours and weekend work
Required Education and Experience
- 3+ years of hands-on US charge audit, DRG audit, or itemized bill review experience in a healthcare provider or vendor environment .
- Bachelor’s degree or combination of education and strong revenue cycle auditing tenure .
- Active baseline coding credential from AHIMA (CCS) or AAPC (CPC, COC, CIC).
- Hands -on experience with at least one major EHR system (Epic Resolute, Cerner Patient Accounting, Meditech, or Athena).
- Practical understanding of US payment methodologies and the ability to review payer contracts to verify allowed units and reimbursement rules .
- Strong working knowledge of inpatient and outpatient clinical documentation expectations, with proven ability to evaluate operative notes, MARs, and clinical records to substantiate billed CPT/HCPCS/ICD -10 codes.
- Working fluency in NCCI, OCE, LCD/NCD guidelines, revenue codes, modifiers, MS -DRG/APR-DRG fundamentals, and OPPS APC.
Preferred Education and Experience
- Active AHIMA CPMA credential.
- Hands-on exposure to specialized audit platforms (e.g., MD-Audit, EXL, Conifer, or Equian products).
- Direct experience defending billed charges and managing ADR workflows under RAC/MAC/OIG frameworks or against major payment integrity vendors.
- Deep coding expertise in high-complexity clinical specialties (e.g., Cardiology, Orthopedics, Oncology, Interventional Radiology) alongside general charge audit depth