[Hiring] Lead Associate, Itemized Bill Review Quality Auditor @Gainwell Technologies LLC

Role Description

We are seeking a talented individual for a Lead Associate, Itemized Bill Review Quality Auditor to perform reviews of medical records, healthcare claims, itemized medical bills, and UB-04 forms to ensure accuracy, compliance, and proper billing practices. This role is responsible for conducting quality assurance audits and oversight of itemized bill review activities to ensure accuracy, consistency, regulatory compliance, and alignment with client-specific review methodologies. This role serves as a subject matter expert in hospital billing, reimbursement methodologies, payment integrity, and claim auditing.

• Perform quality audits of itemized bill reviews to ensure accuracy, consistency, compliance, and proper documentation.
• Validate audit findings by reviewing itemized bills, medical records, claims, contracts, fee schedules, and supporting documentation.
• Evaluate billing errors, duplicate charges, unsupported services, coding, modifiers, units, reimbursement methods, and compliance requirements.
• Conduct complex audits of institutional claims, itemized bills, and medical records to identify inaccuracies, payment issues, and compliance concerns.
• Review inpatient, outpatient, emergency, ambulatory surgery, and ancillary service charges for billing and reimbursement accuracy.
• Assess revenue codes, charge capture practices, HCPCS, CPT, ICD-10 support, and payer requirements.
• Identify payment integrity opportunities through billing and reimbursement reviews.
• Serve as a subject matter expert in business proposals and assist with training, mentoring, and educating new reviewers.
• Maintain current clinical and coding knowledge and cross-train across multiple claim types to support client needs.

Qualifications

• Associate degree in Health Information Management, Nursing, Healthcare Administration, Business Administration, or related healthcare field required.
• Certified Coder or Registered Nurse with Coding Experience. One of the following Coding Certifications preferred: RHIA, RHIT, CCS, CIC, CPMA, CCDS, COC or CPC.
• Comprehensive knowledge of Revenue Codes, CPT, HCPCS, ICD-10 Coding Guidelines, Charge Master structure, UB-O4 billing requirements, APC, ASC, OPPS, DRG reimbursement methodology.
• Advanced knowledge of hospital billing practices, itemized bill review methodologies, and payment integrity concepts.
• Ability to interpret and apply payer contracts, billing regulations, and reimbursement guidelines.
• 3+ years Itemized Bill Review or Hospital Bill Audit experience required.
• 3+ years of outpatient auditing experience with expert knowledge of ICD-10 Official Coding.
• 3+ years medical record review experience or claims auditing preferred.
• 5 years of healthcare billing, coding, payment integrity, revenue cycle, or itemized bill review experience required.
• Experience auditing high-dollar institutional claims.
• Experience auditing hospital itemized bills and institutional claims required.
• Extensive experience reviewing hospital inpatient and outpatient billing practices.

Requirements

• Home based position and you must have a work location within the continental US.
• This position requires that you provide high speed internet connection and a work environment free from distractions.
• Ability to work during normal business hours as this position requires frequent interactions with the team and other departments within the company.
• May be required to work extended hours for special business needs.
• May be required to travel at least 10% of time based on business needs.

Benefits

• The pay range for this position is $60,100.00 - $85,800.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.
• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Educational assistance.
• Leadership and technical development academies to help build your skills and capabilities.