Medical Record Reviewer III (Profee)

Program Integrity Medical Record Reviewer III Location: Remote Compensation: $35 - $42 per hour Contract Length: 6 months with potential for full-time employment Hours: 8am–5pm initially, with flexibility after the first month Start Date: ASAP About The Role Our client is seeking a Program Integrity Medical Record Reviewer III to join their team in a remote, contract-based position with the potential for full-time employment. In this role, you will conduct detailed medical coding reviews of healthcare claims, supporting both pre-pay and post-pay claim reviews across multiple lines of business and specialties. You will play a critical role in ensuring that billed services are accurately supported by medical records and comply with CMS, Medicare, Medicaid, and internal coding guidelines. The position involves identifying coding discrepancies, potential overpayments, and payment integrity concerns, as well as collaborating with Program Integrity and SIU investigators to communicate audit findings and support provider-level decisions. You will thrive in a fast-paced, production- and quality-driven environment, maintaining high productivity and quality standards while ensuring compliance with all regulatory and organizational requirements. What You'll Do Perform detailed, line-level medical coding reviews of healthcare claims. Review medical records and compare documentation against submitted claims to determine if billed services are supported by the medical record and applicable coding requirements. Apply CMS coding and billing guidelines, State Medicaid requirements, Medicare requirements, official coding guidelines, and internal coding and payment policies to claim reviews. Review a broad range of claim types, including professional claims, E/M services, DRG, sepsis, readmissions, laboratory services, and other specialty-specific claims. Identify coding discrepancies, unsupported services, potential overpayments, and other payment integrity concerns. Maintain established productivity and quality standards, with current production averages of 4–5 claims per hour and expectations to increase as workflow is streamlined. Participate in ongoing quality assurance processes, including review of completed claims, responding promptly to feedback, and making necessary corrections. Collaborate with Program Integrity and SIU investigators to communicate audit findings and support provider-level decisions. Help identify trends or patterns that may warrant additional provider review, education, or investigation. Maintain compliance with all applicable regulatory, coding, and organizational requirements. Respond quickly to feedback and incorporate quality assurance recommendations, with target quality accuracy of approximately 90%. What You Bring Extensive experience in medical coding and billing review, including pre-pay and post-pay claim review processes. Thorough knowledge of CMS, Medicare, and State Medicaid coding guidelines, as well as official coding guidelines and payer-specific policies. Ability to review and analyze a broad range of claim types (e.g., professional, E/M, DRG, sepsis, readmissions, laboratory, and specialty claims). Strong attention to detail in identifying coding discrepancies, unsupported services, and payment integrity concerns. Demonstrated ability to maintain productivity and quality standards in a high-volume, production- and quality-driven environment. Effective communication and collaboration skills, with experience working alongside audit and investigation teams. Commitment to compliance with regulatory and organizational requirements, and proficiency in responding to feedback and incorporating quality assurance recommendations. Ability to quickly adapt to new workflows and case management platforms, with a focus on continuous improvement and accuracy. What's In It For You Remote work flexibility Opportunity for contract-to-full-time employment Competitive hourly compensation Engagement in a mission-driven, quality-focused team Professional growth in a dynamic healthcare environment Disclaimer: Brooksource, Medasource, and Calculated Hire are part of the Eight Eleven Group family of companies and operate under Eight Eleven Group, LLC. All employees receive the same benefits, policies, and terms of employment. EEO: We are committed to creating an inclusive environment for all employees and applicants. We do not discriminate on the basis of race, color, religion, creed, sex, sexual orientation, gender identity or expression, national origin, ancestry, age, disability, genetic information, marital status, military or veteran status, citizenship, pregnancy (including childbirth, lactation, and related conditions), or any other protected status in accordance with applicable federal, state, and local laws. Benefits & Perks: Eight Eleven Group offers competitive medical, dental, vision, Health Savings Account, Dependent Care FSA, and supplemental coverage with plans that can fit each employee's needs. We offer a 401k plan that includes a company match and is fully vested after you become eligible, paid time off, sick time, and paid company holidays. We also offer an Employee Assistance Program (EAP) that provides services like virtual counseling, financial services, legal services, life coaching, etc. Pay Disclaimer: The pay range for this job level is a general guideline only and not a guarantee of compensation or salary. Additional factors considered in extending an offer include (but are not limited to) responsibilities of the job, education, experience, knowledge, skills, and abilities, as well as internal equity, alignment with market data, applicable bargaining agreement (if any), or other law. Medasource