Medical Claims Reviewer (CPC, CCS, RHIT)
Location: Remote,
Job Type: Full-Time
Company: HireAligned
Salary: 70,000 - 95,000
Category: General
Job Description Apply Now
The Medical Claims Reviewer (CPC, CCS, RHIT) plays a vital role in ensuring the integrity and compliance of healthcare billing and claims processes. At Integrity Advantage, this position is responsible for the thorough review and evaluation of medical records, claims, and documentation to ensure adherence to established coding guidelines, medical policies, and regulatory standards. Working in a dynamic remote environment, the Medical Claims Reviewer leverages expertise in coding systems such as CDT, CPT, ICD, DRG, REV, and HCPCS, serving as a crucial resource for identifying potential healthcare fraud schemes and supporting accurate payment determinations.
Medical Claims Reviewers are instrumental in the healthcare revenue cycle, providing detailed analysis of claims to prevent inaccuracies, unnecessary payments, or fraudulent activity. The role involves both pre-payment and post-payment medical record reviews, evaluating the accuracy of codes billed, compliance with payer and federal policies, and ensuring that all procedures are documented and justified according to applicable guidelines. This position also conducts comprehensive research related to medical policies and specific healthcare claims, supporting findings with well-structured reports and recommendations for payer clients.
Effective communication is key in this position. Medical Claims Reviewers must clearly articulate their findings to internal teams, leadership, and clients, supporting transparency and informed decision-making. The role also involves direct participation in provider education calls to explain review outcomes and support ongoing compliance efforts. Additionally, the Medical Claims Reviewer may be called upon to assist in legal proceedings, providing testimony and evidentiary support regarding medical review outcomes.
Continuous process improvement is a significant aspect of this position. Medical Claims Reviewers analyze existing policies and workflows to identify opportunities for increased efficiency and effectiveness, proposing actionable solutions that support the organization’s mission of integrity and accuracy. Staying current with evolving regulations, coding standards, and federal requirements is essential for ongoing success in this field. Confidentiality and discretion are paramount, as the role involves handling sensitive patient and provider information in accordance with legal and ethical guidelines.
At Integrity Advantage, Medical Claims Reviewers are encouraged to actively engage with various projects and initiatives, contributing to the company’s commitment to excellence in healthcare review services. The position offers a challenging and rewarding opportunity to make a direct impact on the quality and accuracy of healthcare delivery. If you are detail-oriented, possess strong analytical skills, and have a passion for ensuring compliance and integrity in healthcare, we invite you to apply for the Medical Claims Reviewer (CPC, CCS, RHIT) position and join our team of dedicated professionals.
Medical Claims Reviewer (CPC, CCS, RHIT) - Summary- Responsible for reviewing medical claims and records for accuracy, compliance, and potential fraud.
- Utilizes advanced coding knowledge (CDT, CPT, ICD, DRG, REV, HCPCS).
- Prepares detailed reports and communicates findings to internal and external stakeholders.
- Supports legal proceedings and provider education efforts.
- Drives process improvements and maintains strict confidentiality in all activities.
- Organize and prioritize assigned medical reviews for payment determinations.
- Apply coding guidelines and medical policies to healthcare claims.
- Review pre-payment and post-payment medical records for accurate billing and compliance.
- Conduct research on medical policies and healthcare claims as needed.
- Prepare well-articulated reports summarizing medical review findings, concerns, and recommendations.
- Communicate findings to internal teams and support client interactions.
- Participate in provider education calls related to review findings.
- Assist in legal proceedings, including providing testimony and evidence.
- Analyze and propose improvements to existing policies and processes.
- Maintain up-to-date knowledge of regulations and coding standards.
- Engage in additional projects as assigned.
- Maintain confidentiality and discretion in all review and investigative activities.
- Competitive compensation package commensurate with experience.
- Benefits may include health insurance, paid time off, and professional development opportunities.
- Remote work flexibility.
- Supportive, collaborative work environment focused on professional growth.
- Certification in medical coding (CPC, CCS, RHIT, or equivalent) strongly preferred.
- Demonstrated expertise in using CDT, CPT, ICD, DRG, REV, and HCPCS coding systems.
- Strong understanding of healthcare billing, fraud detection, and compliance requirements.
- Excellent written and verbal communication skills.
- Ability to analyze complex information and present findings clearly.
- High attention to detail, integrity, and confidentiality.
- Ability to multitask and manage multiple reviews simultaneously.
- Proficiency with standard office and claims management software.
- Detail-oriented and analytical with a strong background in medical claims review.
- Certified professional coder with experience in healthcare compliance.
- Effective communicator comfortable engaging with multiple stakeholders.
- Proactive, adaptable, and committed to upholding the highest ethical standards.
- Thrives in a remote, collaborative environment.
- Integrity Advantage is committed to providing equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state, and local laws.
- Join Integrity Advantage as a Medical Claims Reviewer (CPC, CCS, RHIT) and make a meaningful impact on healthcare accuracy and compliance. Apply now by clicking the job application button to take the next step in your career!