Lead Claims Auditor (QC)

Opportunity Overview:

We are seeking a versatile and highly skilled Lead Claims Auditor to join our dynamic Payment Integrity team. This critical role involves conducting comprehensive professional and facility coding reviewsencompassing both outpatient/professional and inpatient claimsto ensure the accuracy of code assignment DRG/reimbursement and to maximize overpayment identification. If you possess a CPC and/or CCS credential expert knowledge of CPT HCPCS and ICD-10-CM/PCS coding guidelines and a passion for deep analytical auditing you will be instrumental in supporting our commitment to accurate reimbursement solutions. This opportunity requires a self-motivated individual who thrives on precision compliance and continuous learning in a high-growth environment

What youll do:

• Conduct comprehensive coding reviews to ensure accuracy in code assignment and reimbursement. Conduct comprehensive outpatient and professional coding reviews to ensure accuracy in code assignment and reimbursement. Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications.
• Conduct ambulatory surgery center emergency room observation and infusion coding reviews.
• Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications.
• Craft clear concise and well-supported audit findings backed by AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations.
• Utilize advanced DRG encoder tools (such as 3M Webstrat) to drive efficiency and accuracy in audits.
• Meet or exceed company quality and productivity standards including strong uphold rates for appeals.
• Stay ahead of industry trends coding updates and compliance regulations to maintain expert-level knowledge.
• Adhere to HIPAA and company policies and procedures to ensure data security and regulatory compliance.
• Maintain and apply superior knowledge of changes and updates to coding guidelines reimbursement trends and health payment policy language.

ISMS roles and responsibilities

• Good knowledge of Information practices.
• Assist the manager in all the information security activities implementation and maintenance process.
• Ensuring the team and imparted with Competence related to Information security
• Responsible for the implementation of security policies and procedures and report any issues to the Information Security Manager.

• 8-12 years of experience overall
• Expert-level coding knowledge with an in-depth understanding of ICD-10-CM/PCS coding guidelines/Deep understanding of outpatient claims coding and auditing
• Self-motivated and able to work independently in a remote environment while maintaining high performance.
• Expertise in outpatient and professional coding audits to ensure accurate code assignment and compliant reimbursement. Leverage indepth knowledge of coding guidelines and industrystandard tools to identify and maximize potential overpayment recoveries.
• Exceptional time management problem-solving and analytical skills.
• Passion for auditing and a commitment to teamwork collaboration and continuous learning.
• Possess the CCS (Certified Coding Specialist) or CPC (Certified Professional Coder) credentials.
• Superior knowledge of HCPCS CPT ICD-10-CM/PCS coding and US healthcare payment methodologies for Commercial Marketplace Medicare and Medicaid.
• Right candidates will have experience with coding ambulatory surgery clinic claims and hospital observation claims to include injection and infusion claims.
• Excellent candidates will also have experience auditing high-cost drug and/or Durable Medical Equipment claims.
• Completion of a bachelors degree.
• Excellent written and verbal English communication skills strong analytical skills and attention to detail.

Nice-to-haves

• Experience using CMS NCDs/LCDs and clinical criteria guidelines.
• RHIA or RHIT credential.
• Experience working in a start-up or high-growth company environment demonstrating agility and adaptability.
• Familiarity with working with a diverse global team of talent.
• Excellent computer skills and familiarity with a Mac.

Ability to commute/relocate:

• Nacharam Hyderabad Telangana*: Reliably commute or planning to relocate before starting work (Preferred)

Interview Process*:

1. Connect with Talent Acquisition
2. Meet with the Hiring Manager
3. Behavioral Interview(s)
4. Case Study
5. Interview with Senior Leadership

*Subject to change

About Cohere Health:

Cohere Healths clinical intelligence platform and agentic AI-powered solutions connect health plans strategic goals and providers needs optimizing the speed cost and quality of care. With an enterprise approach that streamlines payer-provider decision-making across the care continuumincluding policy prior authorization payment accuracy and morethe company improves collaboration and reduces burden resulting in up to 8x ROI and 94% provider satisfaction.

With the acquisition of ZignaAI we expanded our AI-native platform with a comprehensive Payment Integrity Suite that spans data mining clinical and coding validation authorization and claims reconciliation and end-to-end payment integrity services across pre- and post-pay workflows. By connecting clinical and payment insights our transparent AI-powered solutions help health plans proactively improve payment accuracy reduce waste and vendor dependency strengthen provider relationships and build smarter more efficient payment integrity programs.

Cohere Healths innovations continue to receive industry-wide recognition. Weve been recognized on TIMEs World Top HealthTech Companies 2025 list the 2025 Inc. 5000 list in the Gartner Hype Cycle for U.S. Healthcare Payers (2022-2025) and ranked as a Top 5 LinkedIn Startup for 2023 & 2024.

We cant wait to learn more about you and meet you at Cohere Health!

Equal Opportunity Statement:

Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us its personal.