Job Details

Title: Program Integrity Medical Record Reviewer III

Location: Remote

Compensation: $35 – $42 per hour

Contract Length: 6 months with potential for full-time employment

Hours: 8am–5pm initially, with flexibility after the first month

Start Date: ASAP

ABOUT THE ROLE

Our client is seeking a Program Integrity Medical Record Reviewer III to join their team in a remote, contract-based position with the potential for full-time employment. In this role, you will conduct detailed medical coding reviews of healthcare claims, supporting both pre-pay and post-pay claim reviews across multiple lines of business and specialties. You will play a critical role in ensuring that billed services are accurately supported by medical records and comply with CMS, Medicare, Medicaid, and internal coding guidelines. The position involves identifying coding discrepancies, potential overpayments, and payment integrity concerns, as well as collaborating with Program Integrity and SIU investigators to communicate audit findings and support provider-level decisions. You will thrive in a fast-paced, production- and quality-driven environment, maintaining high productivity and quality standards while ensuring compliance with all regulatory and organizational requirements.

WHAT YOU’LL DO

• Perform detailed, line-level medical coding reviews of healthcare claims.
• Review medical records and compare documentation against submitted claims to determine if billed services are supported by the medical record and applicable coding requirements.
• Apply CMS coding and billing guidelines, State Medicaid requirements, Medicare requirements, official coding guidelines, and internal coding and payment policies to claim reviews.
• Review a broad range of claim types, including professional claims, E/M services, DRG, sepsis, readmissions, laboratory services, and other specialty-specific claims.
• Identify coding discrepancies, unsupported services, potential overpayments, and other payment integrity concerns.
• Maintain established productivity and quality standards, with current production averages of 4–5 claims per hour and expectations to increase as workflow is streamlined.
• Participate in ongoing quality assurance processes, including review of completed claims, responding promptly to feedback, and making necessary corrections.
• Collaborate with Program Integrity and SIU investigators to communicate audit findings and support provider-level decisions.
• Help identify trends or patterns that may warrant additional provider review, education, or investigation.
• Maintain compliance with all applicable regulatory, coding, and organizational requirements.
• Respond quickly to feedback and incorporate quality assurance recommendations, with target quality accuracy of approximately 90%.

WHAT YOU BRING

• Extensive experience in medical coding and billing review, including pre-pay and post-pay claim review processes.
• Thorough knowledge of CMS, Medicare, and State Medicaid coding guidelines, as well as official coding guidelines and payer-specific policies.
• Ability to review and analyze a broad range of claim types (e.g., professional, E/M, DRG, sepsis, readmissions, laboratory, and specialty claims).
• Strong attention to detail in identifying coding discrepancies, unsupported services, and payment integrity concerns.
• Demonstrated ability to maintain productivity and quality standards in a high-volume, production- and quality-driven environment.
• Effective communication and collaboration skills, with experience working alongside audit and investigation teams.
• Commitment to compliance with regulatory and organizational requirements, and proficiency in responding to feedback and incorporating quality assurance recommendations.
• Ability to quickly adapt to new workflows and case management platforms, with a focus on continuous improvement and accuracy.

WHAT’S IN IT FOR YOU

• Remote work flexibility
• Opportunity for contract-to-full-time employment
• Competitive hourly compensation
• Engagement in a mission-driven, quality-focused team
• Professional growth in a dynamic healthcare environment