Job description
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.
Summary
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.
Your role in our mission
Collaborate with cross-functional teams to develop clinical and coding solutions, audit strategies, Itemized Bill Review policies, and payment integrity initiatives.
Design audit focused on billing accuracy, reimbursement validation, charge capture integrity, and payment integrity opportunities.
Develop clinical and coding review criteria to identify billing discrepancies and recovery opportunities.
Use data analysis and research to develop new clinical and coding concepts, targets, edits, and Itemized Bill Review solutions.
Monitor performance, present results to leadership, and recommend improvements.
Support the review of clinical and coding solutions.
Work with analytics, operations, product, and audit teams to bring clinical and coding concepts from development to implementation.
Monitor regulatory and coding guideline changes and adjust rules and programs as needed.
Serve as the SME for Itemized Bill Review policies, reimbursement methodologies, facility billing practices, and audit standards.
Research Medicare, Medicaid, commercial payer, state-specific, and facility billing requirements.
Develop audit rationales and supporting documentation for findings and recoveries.Assist with research, special projects, and ad hoc claim reviews.
Develop clinical and coding content, training, and education to support Clinical Services, Quality, and Appeals teams.
Maintain expertise in clinical and coding programs and provide SME support to account management, sales, clients, and clinical teams.
RFP support and work directly with clients to explain programs, address concerns, and develop proactive solutions.
What we're looking for
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.
What you should expect in this role
Remote opportunity within the U.S.
Applications will be accepted through October 30, 2026.
The pay range for this position is $86,800.00 - $115,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.
Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
Originally posted on Himalayas
Who can apply
Eligible countries: United States. Accepted UTC offsets: UTC-10, UTC-9, UTC-8, UTC-7, UTC-6, UTC-5, UTC+14. Review the full description for employer-specific work authorization, residency and schedule requirements.