Clinical Policy Specialist - Itemized Bill Review; Remote

Clinical Policy Specialist - Itemized Bill Review (Remote)

It takes great medical minds to create powerful solutions that solve some of healthcare's most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you've honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you'll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards.

You'll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

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.

Collaborate with Medical Directors, Clinical Leadership, Product, Analytics, and Innovation teams to develop clinical, coding, and Itemized Bill Review solutions that enhance audit strategies, claim selection processes, and payment integrity outcomes. Design and implement audit concepts, review criteria, and reimbursement validation strategies to identify billing discrepancies, improve facility billing accuracy, support recovery opportunities, and strengthen payment integrity programs. Leverage data analysis, research, and performance monitoring to develop new clinical and coding concepts, evaluate results, recommend process improvements, and optimize program effectiveness.

Monitor changes in clinical and coding guidelines, regulations, and reimbursement policies, updating audit rules and review methodologies to ensure compliance and program alignment. Serve as a subject matter expert for Itemized Bill Review, facility billing practices, reimbursement methodologies, and audit standards, providing guidance to clients, leadership, and cross-functional teams. Develop defensible audit rationales, clinical and coding content, training materials, and documentation while supporting special projects, client discussions, RFP activities, and ongoing program implementation.

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…