Remote Clinical Content Lead

Summary

Join Apixio as a Complex Clinical Review Analyst and perform detailed clinical and coding reviews of facility claims. You will analyze the appropriateness of billed charges against medical records, adhering to client policies and industry standards. Research and develop resources to support claim review determinations, focusing on areas like level of care, experimental services, and Do Not Bill events. This role requires expertise in clinical areas, coding accuracy, and payment integrity, demanding strong analytical and detail-oriented skills. You will collaborate with internal and external partners, contribute to client initiatives, and participate in staff training. This is a production-based role requiring a Bachelor of Science in Nursing (BSN) and relevant experience in claims review, healthcare billing and coding, and payment integrity.

Requirements

• Bachelor of Science in Nursing (BSN) required
• Equivalent experience of 2+ years in complex claims/ itemized bill review
• Equivalent experience of 3+ years in healthcare billing and coding
• Experience and background in healthcare payment integrity industry
• Exceptional research and data analysis skills
• Possess significant attention to detail and excellent written and verbal skills
• Excellent organizational, analytical, and problem-solving skills
• Capable of handling multiple projects in a fast paced, hyper-growth environment
• Strong ability to work independently and work with internal teams communicating change across the business
• Experience working with multiple monitors
• Proven success in a remote working environment
• Proficient in Windows office systems, including the full Microsoft Suite and Teams
• Advanced skills in Microsoft Office (Excel, PowerPoint, Word)
• Experience with various software applications and collaboration with development teams
• Ability to sit or stand for long periods, with occasional stooping and reaching
• May require lifting up to 25 pounds
• Requires a normal range of vision and hearing, with or without accommodations
• Position is not substantially exposed to adverse environmental conditions

Responsibilities

• Perform detailed clinical and coding review of facility claims, including review of the detailed itemized statement, the UB-04, and all medical records
• Assess all clinical aspects of the claim, including the appropriateness of the level of care billed throughout the claim
• Research client specific medical policies, manufacturer information, clinical and coding guidelines to identify experimental and investigation charges, such as treatments, procedures, and supplies
• Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances
• Analyze all medication charges to determine correct pharmacy utilization and potential off-label use
• Review all items billed on an itemized bill in comparison to what is documented in a medical record to determine accuracy from a billing, coding, and clinical perspective
• Assess the claim for charges related to Do Not Bill Events or Hospital Acquired Conditions
• Review, expand, and cultivate resources to build up complex claims review content
• Contribute as a SME to new client initiatives by participating in sales calls and coordinating the completion of test claims
• Responsible for driving value, including content development, reference expansion, and managing the appeal language for client requested response letters
• Collaborate and assist in staff training processes and development of training material as needed
• Comply with company standards regarding productivity and audit accuracy to manage daily assignments and meet client turnaround times
• Assists in special projects and perform other duties as needed
• Act as a subject matter expert for the overall product
• Attends all required meetings

Benefits

• Competitive compensation
• Exceptional benefits, including medical, dental and vision, FSA/HSA
• Generous vacation policy