Claims Auditor

Opportunity Overview:

We are seeking a versatile and highly skilled 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.

What Youll Need:

• 3-5 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.
• 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.

Additional Information:

Reporting to: Connie Yoerges

Team: The role involves working closely with other auditors and the business team to support Cohere Healths payment integrity solutions.

Ability to commute/relocate (preferred):

• Nacharam Hyderabad Telangana*: Reliably commute or planning to relocate before starting work (Preferred)
  *we will be opening a new office in the HITEC City area in early 2026

Interview Process*:

1. Connect with the Hiring Manager for a Preliminary Phone Screening
2. Behavioral Interview(s)
3. Case Study
4. Interview with Senior Leadership

*Subject to change

Internal Applicants: Please discuss your interest with your current manager before applying. For more information about the process check out the Talent Acquisition Confluence page.

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.

Cohere Healths clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration cost containment and healthcare economics. Cohere Health works with over 660000 providers and handles over 12 million prior authorization requests annually. Its responsible AI auto-approves up to 90% of requests for millions of health plan members.

With the acquisition of ZignaAI weve further enhanced our platform by launching our Payment Integrity Suite anchored by Cohere Validate an AI-driven clinical and coding validation solution that operates in near real-time. By unifying pre-service authorization data with post-service claims validation were creating a transparent healthcare ecosystem that reduces waste improves payer-provider collaboration and patient outcomes and ensures providers are paid promptly and accurately.

Cohere Healths innovations continue to receive industry wide recognition. Weve been named to the 2025 Inc. 5000 list and in the Gartner Hype Cycle for U.S. Healthcare Payers (2022-2025) and ranked as a Top 5 LinkedIn Startup for 2023 & 2024. Backed by leading investors such as Deerfield Management Define Ventures Flare Capital Partners Longitude Capital and Polaris Partners Cohere Health drives more transparent streamlined healthcare processes helping patients receive faster more appropriate care and higher-quality outcomes.

The Coherenauts as we call ourselves who succeed here are empathetic teammates who are candid kind caring and embody our core values and principles. We believe that diverse inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive growth-oriented environment that works for everyone.

We cant wait to learn more about you and meet you at ZignaAI a Cohere Health company