Clinical Itemized Billing Specialist - Payment Integrity

Transformcap; United States; On-site; USD 90,000 - 140,000; Full time

Benefits offered by this job

Medical, Dental and Vision benefits

Flexible, paid vacation policy

Direct access to Leadership

Competitive compensation package

Job summary

Alaffia is seeking a Clinical Itemized Bill Reviewer to join our Appeals and Disputes team. You will examine itemized bills, UB-04 forms, medical records, and audit findings to determine whether disputed results should be upheld, modified, or overturned.

Role focuses on high-dollar facility claims, coding accuracy, and clear, defensible written responses to provider disputes, in a fast-paced, high-volume environment with HIPAA compliance.

Qualifications

• 3+ years of experience in Payment Integrity, medical bill review, clinical auditing, claims auditing, or related healthcare claims function.
• Hands-on experience reviewing and responding to provider appeals, disputes, reconsiderations, or challenges to Payment Integrity findings.
• Strong experience performing itemized bill reviews and auditing facility claims, including UB-04s.
• Deep knowledge of medical billing, coding, clinical documentation, and insurance claims.
• Experience evaluating whether billed services and charges are supported by medical records and clinical documentation.
• Strong understanding of coding and reimbursement systems (CPT, ICD-10, HCPCS, revenue codes, DRGs, APCs).
• Experience researching and applying national and/or payer-specific coding, billing, and reimbursement guidelines.
• Ability to translate complex clinical/claims information into clear written responses.
• Attention to detail with ability to manage a high-volume case queue.
• Experience with PHI/HIPAA compliance and standards.

Responsibilities

• Review and investigate provider disputes related to Payment Integrity audit findings.
• Review high-dollar facility claims and itemized bills for potential coding, billing, and payment inaccuracies.
• Analyze original audit findings, UB-04s, itemized bills, medical records, and clinical documentation.
• Compare itemized bills and claim forms against medical records to validate charges.
• Determine whether findings should be upheld, modified, or overturned based on evidence.
• Research and apply relevant guidelines (clinical, coding, billing, payer-specific).
• Develop clear, well-supported written responses to provider disputes.
• Identify inconsistencies between claims, clinical docs, coding, and payments.
• Validate coding, billing, and clinical findings using code sets and guidelines.
• Document case findings, rationale, and final determinations clearly.
• Manage a high-volume queue of provider disputes with accuracy and quality.
• Collaborate with PIA Managers and team members to review complex cases.
• Identify trends across disputes and share insights to improve processes.
• Maintain PHI/HIPAA compliance and applicable regulations.

Skills

Payment Integrity

Medical bill review

Clinical auditing

Claims auditing

Provider disputes

UB-04 review

Coding knowledge

PHI/HIPAA compliance

Communication skills

Team collaboration

Education

CPC

CIC

CRC

CPMA

RN license

Job description

Alaffia is seeking a Clinical Itemized Bill Reviewer to join our Appeals and Disputes team. You will examine itemized bills, UB-04 forms, medical records, and audit findings to determine whether disputed results should be upheld, modified, or overturned.

Role focuses on high-dollar facility claims, coding accuracy, and clear, defensible written responses to provider disputes, in a fast-paced, high-volume environment with HIPAA compliance.