Revenue Integrity QC Auditor

Revenue Integrity

Perform advanced revenue cycle auditing and analysis to
support accurate billing, regulatory compliance, and optimal reimbursement
across hospital and professional services claims. As the Revenue Integrity QC
Auditor, you will conduct pre-billing and retrospective claim audits, evaluate
coding, charging, billing, denial, and reimbursement activity, and identify
financial risks, root causes, and revenue recovery opportunities. This role
collaborates with clinical, operational, coding, compliance, information
technology, and revenue cycle partners to strengthen charge capture, claims
performance, billing accuracy, and revenue integrity practices.

In this role, you will:

* Conduct pre-billing, concurrent, and retrospective audits of hospital and
professional claims to evaluate coding, charging, billing, reimbursement
accuracy, and regulatory compliance.

* Review claims and medical record documentation to identify billing errors,
charge discrepancies, payment variances, denials, compliance risks, and
opportunities for revenue recovery.

* Apply CPT, HCPCS, ICD-10-CM, and ICD-10-PCS coding principles and payer
requirements when evaluating government, managed care, and commercial claims.

* Analyze denials, rejections, stop bills, discharged-not-final-billed
accounts, underpayments, and overpayments to identify root causes and recommend
corrective actions.

* Analyze revenue cycle, claims, denial, reimbursement, and operational data
and develop audit findings, reports, dashboards, scorecards, quality control
metrics, and recommendations for leadership.

* Collaborate with Revenue Integrity, Coding, Patient Business Services,
Compliance, Information Technology, and clinical departments to resolve billing
and reimbursement issues and support corrective action plans.

* Provide guidance and education on coding, charging, billing, documentation,
reimbursement requirements, audit processes, and revenue cycle best practices.

* Support process improvement efforts focused on charge integrity, workflow
effectiveness, revenue recovery, compliance, and reduction of revenue loss.

Required

* Bachelor's degree in Health Information Management, Healthcare
Administration, Finance, Business Administration, Accounting, or a related
field, or an equivalent combination of education and experience.

* Eight or more years of progressively responsible experience in healthcare
revenue cycle, revenue integrity, claims auditing, coding, reimbursement
analysis, or related healthcare financial operations.

* Advanced knowledge of healthcare revenue cycle operations, including charge
capture, billing, coding, claims adjudication, denials management, and
reimbursement methodologies.

* Expertise in CPT, HCPCS, ICD-10-CM, and ICD-10-PCS coding principles and
their application within healthcare claims auditing.

* Knowledge of Medicare, Medi-Cal, managed care, and commercial payer billing
requirements and reimbursement regulations.

* Advanced analytical skills with the ability to evaluate complex claims,
financial data, reimbursement trends, and operational workflows.

* Ability to identify root causes of billing errors, denials, compliance risks,
and revenue leakage and develop practical solutions.

* Advanced proficiency with healthcare information systems, revenue cycle
applications, reporting tools, data analysis, dashboard development,
spreadsheet applications, and presentation software.

* Strong written and verbal communication skills with the ability to prepare
concise audit reports, findings, and recommendations and explain technical
revenue cycle concepts to diverse audiences.

* Ability to manage multiple projects, competing priorities, and deadlines in a
fast-paced healthcare environment.

* Ability to collaborate effectively with clinical, operational, compliance,
financial, and technical stakeholders.

Preferred

* CCS (Certified Coding Specialist) certification.

* CCS-P (Certified Coding Specialist, Physician-based) certification.

* CPC (Certified Professional Coder) certification.

* CPMA (Certified Professional Medical Auditor) certification.

* CRCR (Certified Revenue Cycle Representative) certification.

* Experience supporting revenue cycle process improvement, workflow redesign,
or revenue recovery initiatives within an academic health system or large
healthcare organization.

* Familiarity with Epic/CareConnect, Clarity, Cirius, and other healthcare
revenue cycle reporting platforms.