Lead Claims Auditor (QC)

The role

The Lead Claims Auditor conducts professional and facility coding reviews for outpatient and inpatient claims. This role focuses on ensuring accurate code assignment and DRG reimbursement to maximize overpayment identification.

What you will do

• Conduct comprehensive coding reviews for outpatient and professional claims.
• Conduct ambulatory surgery center, emergency room, observation and infusion coding reviews.
• Apply coding guidelines and industry-leading tools to maximize overpayment identifications.
• Craft clear, concise, and well-supported audit findings using AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations.
• Utilize advanced DRG encoder tools such as 3M and Webstrat.
• Meet or exceed company quality and productivity standards.
• Stay ahead of industry trends, coding updates, and compliance regulations.
• Adhere to HIPAA and company policies and procedures.
• Assist the manager in information security activities implementation and maintenance.
• Implement security policies and procedures and report 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
• Ability to work independently in a remote environment
• Expertise in outpatient and professional coding audits
• CCS (Certified Coding Specialist) or CPC (Certified Professional Coder) credentials
• Superior knowledge of HCPCS, CPT, ICD-10-CM/PCS coding, and US healthcare payment methodologies for Commercial, Marketplace, Medicare, and Medicaid
• Experience with coding ambulatory surgery clinic claims and hospital observation claims including injection and infusion claims
• Completion of a bachelor's degree
• Excellent written and verbal English communication skills
• Strong analytical skills
• Attention to detail

Nice to have

• Experience auditing high-cost drug and/or Durable Medical Equipment claims
• Experience using CMS NCDs/LCDs and clinical criteria guidelines
• RHIA or RHIT credential
• Experience working in a start-up or high-growth company environment
• Familiarity with working with a diverse, global team of talent
• Excellent computer skills and familiarity with a Mac

Before you apply

• Connect with Talent Acquisition
• Meet with the Hiring Manager
• Behavioral Interview(s)
• Case Study
• Interview with Senior Leadership

About the company

Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs. The company improves collaboration and reduces burden through an enterprise approach that streamlines payer-provider decision-making.