Claim Review Specialist in United States at Jobgether

This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Claim Review Specialist in United States.

This role sits at the intersection of clinical coding expertise and revenue cycle integrity, supporting healthcare clients through detailed claim review and audit processes. You will analyze hospital outpatient and professional fee claims using specialized tools to identify coding, billing, and documentation discrepancies. Working closely with leadership and consulting teams, you will help translate complex reimbursement rules into clear, actionable insights for clients. The position is fully remote and designed for professionals who thrive in detail-heavy, analytical environments. You will contribute directly to improving financial accuracy and compliance across healthcare organizations. Strong communication skills are essential, as you will also support client education and respond to coding inquiries. This is a high-impact role where precision and expertise directly influence revenue outcomes and client satisfaction.

In this role, you will support claim audit activities and revenue cycle consulting efforts by reviewing, analyzing, and validating complex healthcare claims. You will leverage proprietary tools and regulatory knowledge to ensure accuracy in coding, billing, and reimbursement alignment. You will also collaborate with internal teams and clients to deliver clear insights and recommendations that improve processes and outcomes.

• Conduct detailed audits of outpatient and professional fee claims to identify coding, billing, and documentation issues
• Analyze claims using CMS, Medicaid, and payer-specific guidelines to ensure compliance and accuracy
• Use proprietary software tools to select, organize, and review claims based on data trends and audit priorities
• Support the development of standardized reports, client presentations, and educational materials
• Respond to coding-related questions and assist in client communication with clear, professional guidance
• Contribute to documentation improvement and revenue cycle optimization initiatives

The ideal candidate brings deep expertise in medical coding and revenue cycle processes, along with strong analytical and communication skills. You are comfortable working independently in a highly detail-oriented environment and can interpret complex regulatory frameworks with accuracy.

• 5+ years of directly related experience in revenue cycle, outpatient coding, or healthcare auditing
• Certification required (CCS, COC, or CPC)
• Strong knowledge of outpatient coding (ER, SDS, OBS, Profee, E/M facility, ancillary services)
• Solid understanding of CMS guidelines, ICD-10-CM, CPT/HCPCS, and payer-specific billing rules
• Experience with revenue cycle workflows, denial management, and charge capture processes
• Proficiency in Microsoft Excel, Word, PowerPoint, and documentation tools
• Strong analytical thinking, attention to detail, and independent decision-making skills
• Excellent written and verbal communication skills, with the ability to simplify complex coding topics

• Fully remote work arrangement (USA-based)
• Opportunity to work with advanced healthcare analytics and proprietary audit tools
• Professional development in revenue cycle consulting and clinical coding expertise
• Exposure to complex, high-impact healthcare audit projects
• Collaborative, mission-driven environment focused on client success
• Support for maintaining certifications and continuing education
• Comprehensive workplace tools and structured consulting processes