Lead Claims Auditor (QC)

Opportunity Overview

Lead Claims Auditor – Payment Integrity team. Conduct comprehensive professional and facility coding reviews (outpatient, professional, inpatient) to ensure accurate code assignment, DRG reimbursement, and identify overpayments. Must have CPC and/or CCS credential, expert knowledge of CPT, HCPCS, ICD‑10‑CM/PCS coding guidelines, and a passion for analytical auditing. Self‑motivated, precision‑oriented, compliant, and continuous learner in a high‑growth environment.

What you’ll do

• Conduct comprehensive coding reviews to ensure accuracy in code assignment and reimbursement across all claim types.
• Review ambulatory surgery center, emergency room, observation and infusion coding.
• Craft clear, concise audit findings backed by AHA Coding Clinic Guidelines and ICD‑10‑CM/PCS regulations.
• Utilize advanced DRG encoder tools (e.g., 3M, Webstrat) to drive audit efficiency and accuracy.
• Meet or exceed company quality and productivity standards, including strong appeal uphold rates.
• Stay ahead of industry trends, coding updates, and compliance regulations to maintain expert‑level knowledge.
• Adhere to HIPAA and company policies to ensure data security and regulatory compliance.
• Maintain and apply superior knowledge of coding guideline updates, reimbursement trends, and health payment policy language.

Required Qualifications

• 8‑12 years of experience overall in coding or claims audit.
• Expert‑level coding knowledge with deep understanding of ICD‑10‑CM/PCS guidelines and outpatient claims auditing.
• Ability to work independently in a remote environment while maintaining high performance.
• Exceptional time‑management, problem‑solving, and analytical skills.
• Passion for auditing and a commitment to teamwork, collaboration, and continuous learning.
• Certification: CCS (Certified Coding Specialist) or CPC (Certified Professional Coder).
• Superior knowledge of HCPCS, CPT, ICD‑10‑CM/PCS coding, and U.S. healthcare payment methodologies across Commercial, Marketplace, Medicare, and Medicaid.
• Experience auditing ambulatory surgery clinic claims and hospital observation claims, including injection and infusion claims.
• Experience auditing high‑cost drug and/or durable medical equipment claims.
• Bachelor’s degree completed.
• Excellent written and verbal English communication skills, strong analytical skills, and attention to detail.

Nice‑to‑haves

• Experience using CMS NCDs/LCDs and clinical criteria guidelines.
• RHIA or RHIT credential.
• Experience working in a start‑up or high‑growth company environment.
• Familiarity with collaborating on a diverse, global team.
• Excellent computer skills and familiarity with a Mac.

Equal Opportunity Statement

Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all.