Lead Claims Auditor (QC)

Opportunity Overview: We are seeking a versatile and highly skilled Lead Claims Auditor to join our dynamic Payment Integrity team. This critical role involves conducting comprehensive professional and facility coding reviews—encompassing both outpatient/professional and inpatient claims—to ensure the accuracy of code assignment, DRG/reimbursement, and to maximize overpayment identification. If you possess a CPC and/or CCS credential, expert knowledge of CPT, HCPCS, and ICD-10-CM/PCS coding guidelines, and a passion for deep analytical auditing, you will be instrumental in supporting our commitment to accurate reimbursement solutions. This opportunity requires a self-motivated individual who thrives on precision, compliance, and continuous learning in a high-growth environment What you’ll do: Conduct comprehensive coding reviews to ensure accuracy in code assignment and reimbursement. Conduct comprehensive outpatient and professional coding reviews to ensure accuracy in code assignment and reimbursement. Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications. Conduct ambulatory surgery center, emergency room, observation and infusion coding reviews. Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications. Craft clear, concise, and well-supported audit findings, backed by AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations. Utilize advanced DRG encoder tools (such as 3M, Webstrat) to drive efficiency and accuracy in audits. Meet or exceed company quality and productivity standards, including strong uphold rates for appeals. Stay ahead of industry trends, coding updates, and compliance regulations to maintain expert-level knowledge. Adhere to HIPAA and company policies and procedures to ensure data security and regulatory compliance. Maintain and apply superior knowledge of changes and updates to coding guidelines, reimbursement trends, and health payment policy language. ISMS roles and responsibilities Good knowledge of Information practices. Assist the manager in all the information security activities implementation and maintenance process. Ensuring the team and imparted with Competence related to Information security Responsible for the implementation of security policies and procedures and report any issues to the Information Security Manager. Required Qualifications 8-12 years of experience overall Expert-level coding knowledge with an in-depth understanding of ICD-10-CM/PCS coding guidelines/Deep understanding of outpatient claims coding and auditing Self-motivated and able to work independently in a remote environment while maintaining high performance. Expertise in outpatient and professional coding audits to ensure accurate code assignment and compliant reimbursement. Leverage in‑depth knowledge of coding guidelines and industry‑standard tools to identify and maximize potential overpayment recoveries.