At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our purpose is simple - we strive to bend the cost curve in healthcare for all. Our dedication to service excellence extends to all our stakeholders – internal and external - driving us to consistently exceed expectations. We are intentionally bold, we foster innovation, we nurture accountability, we champion diversity, and empower each other to illuminate our collective potential.
Be part of our amazing transformational journey as we optimize the opportunity towards becoming a leading technology, data, and innovation voice in healthcare. Onward and Upward!!!
At Claritev , we pride ourselves on being a dynamic team of innovative professionals. Our mission is simple: to bend the cost curve in healthcare for all.
Our commitment to service excellence extends to both internal and external stakeholders, driving us to consistently exceed expectations. We operate with intention and purpose. We foster innovation, champion diversity, nurture accountability, and empower each other to reach our collective potential.
Join us as we continue our transformational journey to become a leading voice in healthcare technology, data, and innovation.
The Senior DRG Clinical Auditor analyzes high-dollar and highly complex healthcare claims to ensure accurate billing practices and regulatory compliance.
In this role, you will apply advanced clinical knowledge, coding standards, industry expertise, and federal regulations to review itemized hospital bills and claim documentation . You will identify billing abnormalities, unbundling, questionable billing practices, and improper coding combinations, while documenting findings and denial rationale.
This role also serves as a subject matter expert, supporting clinical review teams, operational efficiency, and coding education initiatives.
- Strong working knowledge of DRG reimbursement methodology (REQUIRED)
- Review and analyze complex inpatient and outpatient charges across various revenue centers.
- Evaluate charges based on patient diagnosis, procedures, age, facility type, and related documentation.
- Perform detailed itemized bill reviews to identify unbundling, duplicate charges, improper coding combinations, and billing irregularities.
- Apply national coding standards, federal regulations, and industry best practices to claims review.
- Research and review claims, operative notes, claim trends, and itemized billing documentation.
- Document audit results and update systems accordingly.
- Ensure claim reviews comply with HIPAA regulations, reimbursement policies, and federal/state guidelines .
- Monitor coding trends, regulatory updates, and industry practices impacting claim accuracy.
- Apply clinical judgment and analytical expertise to review highly complex or escalated claims.
- Identify opportunities for cost recovery and overpayment prevention .
- Research and recommend improvements to reduce billing errors and increase operational efficiency.
- Monitor turnaround times and recommend process enhancements.
- Provide guidance to coders, negotiators, physicians, and internal teams on clinical and coding issues.
- Participate in training, mentoring, and onboarding of new and existing staff.
- Develop educational materials and job aids related to coding and claim review processes.
- Support negotiation strategies by providing coding insights and claim review findings.
- Partner with physician advisors, analytics teams, and leadership to enhance coding edits, claim factors, and reference materials.
- Communicate coding, reimbursement, and clinical findings clearly to internal teams and leadership.
- Collaborate across departments to support departmental and organizational goals.
- Assist management with operational support and departmental initiatives.
- Evaluate performance of new and existing team members when applicable.
- Demonstrate commitment to company values and organizational objectives.
- Due to exposure to Protected Health Information (PHI) , this role is classified as a High Risk Role .
- Perform additional duties as assigned.
This role operates independently with minimal supervision while managing multiple complex audits simultaneously.
The Senior Clinical Auditor applies deep expertise in healthcare coding, billing practices, reimbursement models, and regulatory requirements to review claims and resolve complex billing issues. More complex cases may be escalated to senior leadership as appropriate.
The salary range for this position is $80,000 – $85,000 annually .
Requirements: Required
High school diploma and 5+ YEARS OF DRG BILL REVIEW EXPERIENCE (REQUIRED) , OR completion of required educational curriculum for a medical license or coding certification.
Extensive knowledge of inpatient and outpatient hospital billing , including:
UB-04 forms
Revenue codes
CPT codes
HCPCS codes
ICD-10 diagnoses and procedures
Strong medical knowledge to identify inappropriate or questionable charges.
Strong working knowledge of DRG reimbursement methodology (REQUIRED)
Familiarity with payer reimbursement policies, regulatory standards, and medical necessity criteria.
Experience reviewing medical records and claim documentation .
Preferred
Bachelor’s degree in a related field.
Certified coding credential (CPC, CCS, RHIT, RHIA, or similar).
Experience in healthcare auditing or health information management .
Skills
Strong analytical and problem-solving skills
Excellent communication and interpersonal abilities
Experience interpreting provider contracts and reimbursement policies
Proficiency with Microsoft Office (Excel, Outlook, PowerPoint) ; Visio a plus
Ability to manage multiple priorities in a fast-paced environment
Ability to mentor and educate team members
BENEFITS
We realize that our employees are instrumental to our success, and we reward them accordingly with very competitive compensation and benefits packages, an incentive bonus program, as well as recognition and awards programs. Our work environment is friendly and supportive, and we offer flexible schedules whenever possible, as well as a wide range of live and web-based professional development and educational programs to prepare you for advancement opportunities.
Your benefits will include:
Medical, dental and vision coverage with low deductible & copay
Life insurance
Short and long-term disability
Paid Parental Leave
401(k) + match
Employee Stock Purchase Plan
Generous Paid Time Off – accrued based on years of service
WA Candidates: the accrual rate is 4.61 hours every other week for the first two years of tenure before increasing with additional years of service
10 paid company holidays
Tuition reimbursement
Flexible Spending Account
Employee Assistance Program
Sick time benefits – for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year, unless the laws of the state in which the employee is located provide for more generous sick time benefits.
EEO STATEMENT
Claritev is an Equal Opportunity Employer and complies with all applicable laws and regulations. Qualified applicants will receive consideration for employment without regard to age, race, color, religion, gender, sexual orientation, gender identity, national origin, disability or protected veteran status. If you would like more information on your EEO rights under the law, .
APPLICATION DEADLINE
We will generally accept applications for at least 5 calendar days from the posting date or as long as the job remains posted.
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