Clinical Policy Specialist – Itemized Bill Review

This is a fully remote position, open to applicants in Texas.

📋 Description

• Collaborate with Medical Directors, Clinical Leadership, Product, Analytics, and Innovation teams to create solutions for clinical, coding, and Itemized Bill Review.

• Design and execute audit concepts, review criteria, and strategies for reimbursement validation.

• Identify discrepancies in billing and enhance the accuracy of facility billing.

• Support recovery initiatives and reinforce payment integrity programs.

• Utilize data analysis, research, and performance monitoring to formulate clinical and coding concepts.

• Assess results, suggest process enhancements, and maximize program effectiveness.

• Keep track of changes in clinical and coding guidelines, regulations, and reimbursement policies.

• Revise audit rules and review methodologies to ensure compliance and program alignment.

• Act as a subject matter expert in Itemized Bill Review, facility billing practices, reimbursement methodologies, and auditing standards.

• Offer guidance to clients, leadership, and cross-functional teams.

• Create audit rationales, clinical and coding content, training materials, and documentation.

• Assist with special projects, client discussions, RFP activities, and the implementation of ongoing programs.

⛳️ Requirements

• Associate’s Degree is required; Bachelor's degree is preferred (in health administration, business, or nursing).

• Hold an active, unrestricted RN license from the United States and in the primary home state of residence.

• Possess an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

• Have at least one coding certification: RHIA, RHIT, CCS, CCS-P, CIC, CPC, CPMA, or an equivalent clinical/coding credential.

• Accumulate 5+ years of experience in payment integrity, healthcare reimbursement, facility claims auditing, medical bill review, DRG validation, revenue integrity, or clinical policy development.

• Gain 5+ years of experience in performing Itemized Bill Review or Medical Bill Review auditing for facility claims.

• Acquire 3+ years of experience with healthcare policy, Medicare guidelines, and the research and interpretation of State regulations.

• Demonstrate extensive knowledge of Medicare and Medicaid reimbursement methodologies, hospital billing practices, UB-04 claims, coding guidelines, and revenue cycle processes.

• Have experience in developing audit concepts, review criteria, policies, or solutions for payment integrity.

• Exhibit the ability to research State and Federal regulations, clinical policies, and coding guidelines.

• Be a resident based in the U.S.

🏝️ Benefits

• Flexible hours.

• Work-life balance.

• Opportunities for continuous learning and career development.

• A flexible vacation policy.

• 401(k) employer match.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development academies.