Clinical Auditor

Why This Role Matters

• As a Clinical Claims Auditor, you will play a critical role in protecting healthcare organizations and clients from inaccurate billing, coding errors, and inappropriate claim payments. By applying advanced clinical, coding, and reimbursement expertise, you will review high-dollar and highly complex inpatient and outpatient claims to identify billing discrepancies, payment integrity opportunities, and areas of financial risk.
• Your work directly supports cost containment, regulatory compliance, and overall payment accuracy by ensuring claims are evaluated against industry standards, coding regulations, medical necessity requirements, and reimbursement policies. Through detailed analysis and expert judgment, you will help uncover opportunities for claim recovery, prevent future overpayments, and contribute to better healthcare financial outcomes.
• This is an exciting opportunity for a healthcare auditing professional who enjoys complex problem-solving, leveraging clinical and coding expertise, and serving as a trusted resource within a collaborative, fast-paced environment.

What You'll Do

In this role, you will have the opportunity to:

• Review and analyze complex inpatient and outpatient claims, itemized bills, and supporting documentation to identify billing inaccuracies, unbundling, and inappropriate charges.
• Apply clinical expertise, coding standards, and reimbursement guidelines to evaluate high-dollar and highly complex claims.
• Identify opportunities for payment recovery, cost avoidance, and process improvements that enhance payment integrity outcomes.
• Research claim trends, coding practices, regulatory updates, and reimbursement requirements to support accurate claim reviews and audit findings.
• Document audit results, denial rationales, and claim findings while maintaining accurate and complete records.
• Serve as a subject matter expert and resource for teammates by providing guidance on coding, reimbursement, auditing, and clinical review practices.
• Utilize independent judgment to assess challenging cases, interpret medical documentation, and determine appropriate courses of action.
• Communicate clinical, coding, and reimbursement findings to stakeholders in a clear, organized, and actionable manner.
• Partner with leadership to support departmental goals, operational improvements, and process efficiency initiatives.
• Ensure compliance with HIPAA requirements and industry regulations while handling protected health information.

What You Will Bring

Required Qualifications

• Completion of the educational requirements associated with an active medical license or coding certification.
• Minimum of five (5) years of coding experience.
• Minimum of five (5) years of experience in direct patient care, medical procedure billing, medical insurance auditing, line-item review, coding, reimbursement, or related healthcare functions.
• Extensive knowledge of inpatient and outpatient hospital billing practices, including UB-04 forms, revenue codes, itemized billing, CPT codes, HCPCS codes, and ICD-10 diagnosis and procedure coding.
• Strong understanding of payer reimbursement methodologies, medical necessity requirements, state and federal regulations, and healthcare industry standards.
• Ability to review, interpret, and abstract medical records and supporting clinical documentation.
• Knowledge of medical terminology, anatomy, physiology, and healthcare reimbursement processes.
• Proficiency with Microsoft Office applications, including Excel, Outlook, and PowerPoint.
• Strong analytical, problem-solving, organizational, communication, and time-management skills.
• Ability to manage multiple priorities, meet deadlines, and work independently with minimal supervision.
• Ability to interact professionally with providers and other healthcare stakeholders.

Preferred Qualifications

• Bachelor's degree.
• Experience in health information management, healthcare auditing, or payment integrity programs.
• Experience conducting facility contract interpretation and reimbursement analysis.
• Experience developing educational materials, training resources, or coding-related job aids.
• Experience mentoring, coaching, or training team members.
• Advanced expertise reviewing itemized bills, operative reports, and complex clinical documentation.
• Experience supporting process improvement initiatives within healthcare auditing, coding, or reimbursement operations.

Compensation

The salary range for this position is $75,000-$80,000.

Actual compensation is based on experience, skills, education, work location, and internal equity. This position may also be eligible for incentive compensation and the comprehensive benefits outlined in the My Total Value section. Benefits include health insurance, a 401(k) program, and bonus opportunities.

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Why Claritev?

Healthcare is complex. We help make it clearer.

At Claritev, you'll do work that matters. Together, we're helping make healthcare more transparent and affordable for all through the power of data, technology, and expertise. We offer meaningful opportunities to grow your career, collaborate with talented colleagues, and make an impact on the clients and communities we serve. If you're looking for purpose, growth, and a team that succeeds together, you'll find it here.

What Guides Us

At Claritev, innovation, agility, and a focus on results drive our success. We embrace bold thinking, work as one team, take ownership, and strive for excellence in everything we do - creating meaningful impact for our clients, communities, and each other.