Revenue Integrity QC Auditor

Revenue Integrity

Perform advanced revenue cycle auditing and analysis to support accurate billing, regulatory compliance, and optimal reimbursement across hospital and professional services claims. As the Revenue Integrity QC Auditor, you will conduct pre-billing and retrospective claim audits, evaluate coding, charging, billing, denial, and reimbursement activity, and identify financial risks, root causes, and revenue recovery opportunities. This role collaborates with clinical, operational, coding, compliance, information technology, and revenue cycle partners to strengthen charge capture, claims performance, billing accuracy, and revenue integrity practices.

In this role, you will:
• Conduct pre-billing, concurrent, and retrospective audits of hospital and professional claims to evaluate coding, charging, billing, reimbursement accuracy, and regulatory compliance.
• Review claims and medical record documentation to identify billing errors, charge discrepancies, payment variances, denials, compliance risks, and opportunities for revenue recovery.
• Apply CPT, HCPCS, ICD-10-CM, and ICD-10-PCS coding principles and payer requirements when evaluating government, managed care, and commercial claims.
• Analyze denials, rejections, stop bills, discharged-not-final-billed accounts, underpayments, and overpayments to identify root causes and recommend corrective actions.
• Analyze revenue cycle, claims, denial, reimbursement, and operational data and develop audit findings, reports, dashboards, scorecards, quality control metrics, and recommendations for leadership.
• Collaborate with Revenue Integrity, Coding, Patient Business Services, Compliance, Information Technology, and clinical departments to resolve billing and reimbursement issues and support corrective action plans.
• Provide guidance and education on coding, charging, billing, documentation, reimbursement requirements, audit processes, and revenue cycle best practices.
• Support process improvement efforts focused on charge integrity, workflow effectiveness, revenue recovery, compliance, and reduction of revenue loss.

Required
• Bachelor’s degree in Health Information Management, Healthcare Administration, Finance, Business Administration, Accounting, or a related field, or an equivalent combination of education and experience.
• Eight or more years of progressively responsible experience in healthcare revenue cycle, revenue integrity, claims auditing, coding, reimbursement analysis, or related healthcare financial operations.
• Advanced knowledge of healthcare revenue cycle operations, including charge capture, billing, coding, claims adjudication, denials management, and reimbursement methodologies.
• Expertise in CPT, HCPCS, ICD-10-CM, and ICD-10-PCS coding principles and their application within healthcare claims auditing.
• Knowledge of Medicare, Medi-Cal, managed care, and commercial payer billing requirements and reimbursement regulations.
• Advanced analytical skills with the ability to evaluate complex claims, financial data, reimbursement trends, and operational workflows.
• Ability to identify root causes of billing errors, denials, compliance risks, and revenue leakage and develop practical solutions.
• Advanced proficiency with healthcare information systems, revenue cycle applications, reporting tools, data analysis, dashboard development, spreadsheet applications, and presentation software.
• Strong written and verbal communication skills with the ability to prepare concise audit reports, findings, and recommendations and explain technical revenue cycle concepts to diverse audiences.
• Ability to manage multiple projects, competing priorities, and deadlines in a fast-paced healthcare environment.
• Ability to collaborate effectively with clinical, operational, compliance, financial, and technical stakeholders.

Preferred
• CCS (Certified Coding Specialist) certification.
• CCS-P (Certified Coding Specialist, Physician-based) certification.
• CPC (Certified Professional Coder) certification.
• CPMA (Certified Professional Medical Auditor) certification.
• CRCR (Certified Revenue Cycle Representative) certification.
• Experience supporting revenue cycle process improvement, workflow redesign, or revenue recovery initiatives within an academic health system or large healthcare organization.
• Familiarity with Epic/CareConnect, Clarity, Cirius, and other healthcare revenue cycle reporting platforms.