Clinical Policy Specialist - Itemized Bill Review (Any city, TX, US, 99999)

The Clinical Policy Specialist – Itemized Bill Review is responsible for the development, enhancement, and performance of Itemized Bill Review clinical and coding solutions. This role serves as the primary subject matter expert for Itemized Bill Review policies, methodologies, and audit strategies, leveraging expertise in healthcare reimbursement, facility billing, revenue integrity, coding, payment policies, and regulatory requirements.

The ideal candidate will possess extensive knowledge of inpatient and outpatient facility billing, UB-04 claim processing, itemized bill analysis, coding guidelines, reimbursement methodologies, and payment integrity strategies. This role is responsible for developing and maintaining audit concepts, conducting clinical and coding research, analyzing claims and billing data, monitoring program performance, supporting client implementations, and ensuring content aligns with industry standards and regulatory requirements.

This position plays a critical role in identifying billing vulnerabilities, developing innovative audit strategies, improving claim selection methodologies, and maximizing recovery opportunities while ensuring accurate and defensible review outcomes.

• Associate’s Degree required, Bachelor's degree preferred (health administration, business, nursing)
• Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
• At least one of the following coding certifications RHIA, RHIT, CCS, CCS-P, CIC, CPC, CPMA or equivalent clinical/coding credential.
• 5+ years of experience in payment integrity, healthcare reimbursement, facility claims auditing, medical bill review, DRG validation, revenue integrity, or clinical policy development.
• 5+ years of experience performing Itemized Bill Review or Medical Bill Review auditing facility claims.
• 3+ years of experience with healthcare policy, Medicare guidelines and State regulation research and interpretation.
• Extensive knowledge of Medicare and Medicaid reimbursement methodologies, hospital billing practices, UB-04 claims, coding guidelines, and revenue cycle processes.
• Experience developing audit concepts, review criteria, policies, or payment integrity solutions.
• Ability to research State and Federal regulations, clinical policies, coding guidelines to develop and implement policies, clinical/coding resources, and tools to support Gainwell’s Clinical Claim Review products.