Clinical Policy Specialist – Itemized Bill Review

🔥 12 hours ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $86.8k - $124k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

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

• Collaborate with Medical Directors, Clinical Leadership, Product, Analytics, and Innovation teams to develop clinical, coding, and Itemized Bill Review solutions • Design and implement audit concepts, review criteria, and reimbursement validation strategies • Identify billing discrepancies and improve facility billing accuracy • Support recovery opportunities and strengthen payment integrity programs • Use data analysis, research, and performance monitoring to develop clinical and coding concepts • Evaluate results, recommend process improvements, and optimize program effectiveness • Monitor changes in clinical and coding guidelines, regulations, and reimbursement policies • Update audit rules and review methodologies for compliance and program alignment • Serve as subject matter expert for Itemized Bill Review, facility billing practices, reimbursement methodologies, and audit standards • Provide guidance to clients, leadership, and cross-functional teams • Develop audit rationales, clinical and coding content, training materials, and documentation • Support special projects, client discussions, RFP activities, and ongoing program implementation

🎯 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 • Active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) • 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 • U.S.-based residency

🏖️ Benefits

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