Lead Claims Auditor (QC)

Responsibilities

• Conduct ambulatory surgery center, emergency room, observation and infusion coding reviews.
• Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications.
• Craft clear, concise, and well-supported audit findings, backed by AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations.
• Utilize advanced DRG encoder tools (such as 3M, Webstrat) to drive efficiency and accuracy in audits.
• Meet or exceed company quality and productivity standards, including strong uphold rates for appeals.
• Stay ahead of industry trends, coding updates, and compliance regulations to maintain expert-level knowledge.
• Adhere to HIPAA and company policies and procedures to ensure data security and regulatory compliance.
• Maintain and apply superior knowledge of changes and updates to coding guidelines, reimbursement trends, and health payment policy language.
• Required Qualifications
• 8-12 years of experience overall
• Expert-level coding knowledge with an in-depth understanding of ICD-10-CM/PCS coding guidelines/Deep understanding of outpatient claims coding and auditing
• Self-motivated and able to work independently in a remote environment while maintaining high performance.
• Expertise in outpatient and professional coding audits to ensure accurate code assignment and compliant reimbursement. Leverage in‑depth knowledge of coding guidelines and industry‑standard tools to identify and maximize potential overpayment recoveries.
• Exceptional time management, problem-solving, and analytical skills.
• Passion for auditing and a commitment to teamwork, collaboration, and continuous learning.
• Possess the CCS (Certified Coding Specialist) or CPC (Certified Professional Coder) credentials.
• Superior knowledge of HCPCS, CPT, ICD-10-CM/PCS coding, and US healthcare payment methodologies for Commercial, Marketplace, Medicare, and Medicaid.
• Right candidates will have experience with coding ambulatory surgery clinic claims and hospital observation claims to include injection and infusion claims.
• Excellent candidates will also have experience auditing high-cost drug and/or Durable Medical Equipment claims.
• Completion of a bachelor's degree.
• Excellent written and verbal English communication skills, strong analytical skills, and attention to detail.

Requirements

• Experience using CMS NCDs/LCDs and clinical criteria guidelines.
• RHIA or RHIT credential.
• Experience working in a start-up or high-growth company environment, demonstrating agility and adaptability.
• Familiarity with working with a diverse, global team of talent.
• Excellent computer skills and familiarity with a Mac.
• Ability to commute/relocate:
• Nacharam, Hyderabad, Telangana*: Reliably commute or planning to relocate before starting work (Preferred)
• Interview Process*:
• Connect with Talent Acquisition
• Meet with the Hiring Manager
• Behavioral Interview(s)
• Case Study
• Interview with Senior Leadership
• *Subject to change
• About Cohere Health:

Benefits

Additional Information

Opportunity Overview: We are seeking a versatile and highly skilled Lead Claims Auditor to join our dynamic Payment Integrity team. This critical role involves conducting comprehensive professional and facility coding reviews-encompassing both outpatient/professional and inpatient claims-to ensure the accuracy of code assignment, DRG/reimbursement, and to maximize overpayment identification. If you possess a CPC and/or CCS credential, expert knowledge of CPT, HCPCS, and ICD-10-CM/PCS coding guidelines, and a passion for deep analytical auditing, you will be instrumental in supporting our commitment to accurate reimbursement solutions. This opportunity requires a self-motivated individual who thrives on precision, compliance, and continuous learning in a high-growth environment

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