Clinical Policy Specialist – Itemized Bill Review

🕒 August 25

🇺🇸 United States – Remote

💵 $86.8k - $115k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 24%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Develop, enhance, and support Itemized Bill Review clinical and coding solutions • Collaborate with cross-functional teams on clinical and coding solutions, audit strategies, policies, and payment integrity initiatives • Design audits focused on billing accuracy, reimbursement validation, charge capture integrity, and payment integrity opportunities • Develop clinical and coding review criteria to identify billing discrepancies and recovery opportunities • Use data analysis and research to develop clinical and coding concepts, targets, edits, and Itemized Bill Review solutions • Monitor performance, present results to leadership, and recommend improvements • Support review of clinical and coding solutions • Work with analytics, operations, product, and audit teams to move concepts from development to implementation • Monitor regulatory and coding guideline changes and adjust rules and programs • Serve as subject matter expert for Itemized Bill Review policies, reimbursement methodologies, facility billing practices, and audit standards • Research Medicare, Medicaid, commercial payer, state-specific, and facility billing requirements • Develop audit rationales and supporting documentation for findings and recoveries • Assist with research, special projects, and ad hoc claim reviews • Develop clinical and coding content, training, and education for Clinical Services, Quality, and Appeals teams • Provide subject matter expert support to account management, sales, clients, and clinical teams • Support RFPs and work directly with clients to explain programs, address concerns, and develop proactive solutions

🎯 Requirements

• Associate’s Degree required; Bachelor's degree preferred (health administration, business, nursing) • Active, Unrestricted RN license from the United States and in the primary home residency, or active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required • At least one coding certification: RHIA, RHIT, CCS, CCS-P, CIC, CPC, CPMA or equivalent clinical/coding credential • 5+ years of experience in payment integrity, healthcare reimbursement, facility claims auditing, medical bill review, DRG validation, revenue integrity, or clinical policy development • 5+ years of experience performing Itemized Bill Review or Medical Bill Review auditing facility claims • 3+ years of experience with healthcare policy, Medicare guidelines and State regulation research and interpretation • Extensive knowledge of Medicare and Medicaid reimbursement methodologies, hospital billing practices, UB-04 claims, coding guidelines, and revenue cycle processes • Experience developing audit concepts, review criteria, policies, or payment integrity solutions • Ability to research State and Federal regulations, clinical policies, and coding guidelines to develop and implement policies, clinical/coding resources, and tools • Ability to work remotely within the U.S.

🏖️ Benefits

• Flexible hours • Work-life balance • Continuous learning and career development • Work flexibility • Generous, flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies • Equal Opportunity Employer