Senior Auditor Appeals - OPSP

Job description

Accountabilities Review and evaluate complex claim appeals using clinical documentation, coding guidelines, and regulatory policies Apply official standards such as ICD-10, MS-DRG, APR-DRG, CMS guidelines, and internal clinical validation criteria to determine claim accuracy Prepare detailed, fact-based written determinations explaining audit outcomes to healthcare providers in a clear and professional manner Ensure all assigned appeals meet established service level agreements and productivity expectations Analyze medical records and supporting documentation to identify discrepancies, errors, or justification for claim outcomes Provide subject matter expertise across clinical chart validation and appeals processes, supporting audit consistency and quality Deliver feedback and educational insights to initial audit and QA teams to improve overall performance and accuracy Support additional audit or QA functions as needed based on operational priorities Requirements Bachelor’s or Associate’s degree in Nursing (active, unrestricted license) or Health Information Management (RHIA/RHIT), or equivalent 5+ years of relevant experience 5–7+ years of experience in medical claims auditing, clinical validation, or recovery auditing within healthcare or payer environments Strong expertise in ICD-9/ICD-10 coding, DRG methodologies (MS-DRG, APR-DRG, AP-DRG), and clinical documentation standards Inpatient coding certification (RHIA, RHIT, CCS, or CIC preferred; CCDS or CPC considered with requirement to obtain inpatient certification within 1 year) 3–5 years of experience reviewing medical records and applying coding or reimbursement guidelines in a clinical audit setting Strong understanding of CMS regulations, payer policies, medical necessity criteria, and healthcare billing systems Excellent written and verbal communication skills with the ability to produce clear, defensible audit determinations Strong analytical skills with high attention to detail and ability to work independently in a structured, compliance-driven environment Proficiency with Microsoft Office tools (Excel, Word, Access) and related data review applications Benefits Competitive base salary starting around 101,000 USD annually, with potential discretionary bonus eligibility Comprehensive medical, dental, and vision insurance coverage Disability and life insurance benefits 401(k) retirement savings plan Paid family leave programs Paid time off ranging from 17 to 27 days depending on tenure, plus 9 paid holidays annually Flexible remote work environment (US-based) with home office setup requirements Overtime eligibility for non-exempt employees in accordance with applicable laws How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best! Why Apply Through Jobgether? Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time. #LI-CL1 This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Senior Auditor Appeals - OPSP in the United States. In this specialized clinical auditing role, you will be responsible for reviewing complex healthcare claim determinations and appeals, ensuring accuracy, compliance, and alignment with clinical coding and reimbursement guidelines. You will analyze medical records, prior audit decisions, and provider-submitted documentation to validate or overturn recovery determinations. This role requires deep expertise in clinical validation and coding standards, as well as the ability to communicate clear, well-supported decisions in writing. Acting as a subject matter expert, you will also contribute to improving audit quality by providing feedback to internal teams. The environment is highly detail-driven, regulated, and quality-focused, requiring strong analytical thinking and professional judgment. Your work will directly impact the accuracy and integrity of healthcare payment decisions across complex claim types.