W3R Consulting

Description: Investigates complex healthcare claims flagged by third-party referrals, tips, or external allegations prior to payment. This role combines advanced clinical coding expertise (ICD-10, CPT, HCPCS) with investigative scrutiny. The auditor reviews medical records to verify that documented services match the billed codes, adhere to medical necessity guidelines, and comply with state, federal, and contractual coding regulations. Key responsibilities: Allegation Triaging & Investigation: Analyze incoming third-party referrals, compliance tips, and external fraud allegations to identify specific billing patterns, suspect providers, or unbundled services. Identify potential fraud, waste, abuse, billing irregularities, and patterns of non-compliance through medical record review and claims analysis. Pre-Payment Clinical Review: Perform comprehensive clinical and technical reviews of high-dollar or highly complex medical records before a claim is finalized for payment....

W3R Consulting seeks an experienced healthcare auditor to investigate complex claims and verify coding accuracy before payment. You will combine clinical coding expertise with investigative rigor to ensure medical necessity and regulatory compliance across CPT, HCPCS, ICD-10-CM/PCS coding standards. Please lead pre‑payment reviews, identify fraud or non‑compliance patterns, and prepare audit summaries to inform SIU or Compliance teams as warranted. #J-18808-Ljbffr

Clinical Editing Dispute Review Analyst 1 / Title: Medical Coder Employment Type: Contract, W-2 | 6 Months Right to Hire Schedule: Monday-Friday, 8-hour shifts About the Opportunity W3R Consulting is seeking a detail-oriented Clinical Editing Dispute Review Analyst 1 to join our healthcare operations team. This role is ideal for professionals with experience in medical coding, claims review, clinical editing, and provider dispute resolution. The successful candidate will research and resolve coding-related claim inquiries, review clinical editing disputes, communicate findings, and help ensure accurate and timely claims processing. Key Responsibilities Research, triage, and resolve clinical editing and coding-related claim disputes. Review provider inquiries and collaborate with medical directors, claims teams, clinical reviewers, and external partners to investigate issues. Analyze claim edits, coding discrepancies, reimbursement rules, and claims processing issues....

Description: Investigates complex healthcare claims flagged by third-party referrals, tips, or external allegations prior to payment. This role combines advanced clinical coding expertise (ICD-10, CPT, HCPCS) with investigative scrutiny. The auditor reviews medical records to verify that documented services match the billed codes, adhere to medical necessity guidelines, and comply with state, federal, and contractual coding regulations. Key responsibilities : Allegation Triaging & Investigation: Analyze incoming third-party referrals, compliance tips, and external fraud allegations to identify specific billing patterns, suspect providers, or unbundled services. Identify potential fraud, waste, abuse, billing irregularities, and patterns of non-compliance through medical record review and claims analysis. Pre-Payment Clinical Review: Perform comprehensive clinical and technical reviews of high-dollar or highly complex medical records before a claim is finalized...

Clinical Editing Dispute Review Analyst 1 Location: Remote Schedule: Monday-Friday Job Type: 5 months contract Job Summary Responsible for researching, reviewing, and resolving clinical editing inquiries, claims disputes, and appeals. Collaborates with Medical Directors, Claims, Provider Services, and external vendors to ensure accurate claims processing, timely resolution, and appropriate provider reimbursement. Key Responsibilities Research and resolve clinical editing inquiries, claims disputes, and appeals. Coordinate with Medical Directors, providers, internal teams, and vendors to obtain necessary information. Track inquiries, monitor turnaround times, and maintain review databases and logs. Communicate review decisions and resolutions to providers and stakeholders. Support claim adjustments, claims research, and appeals processing. Prepare weekly metrics, identify trends, and recommend process improvements. Ensure accurate documentation and...