Charge Capture Specialist

Job Description
Essential Job Functions

Pull medical record (H&P, op notes, anesthesia record, MAR, nursing notes, implant logs, pathology, radiology) and itemized bill / UB-04 / 1500 detail and reconcile line by line against billed charges.

Validate CPT / HCPCS / ICD-10-CM / revenue code / modifier / units / DOS against documentation; flag overcharges, undercharges, missing charges, and inappropriate bundling / unbundling.

Apply NCCI PTP, MUE, OCE, and LCD / NCD logic; document defensibility of each line decision.

Defend billed charges against payor / payor-vendor audit findings (Equian / Optum Payment Integrity / Cotiviti / Zelis / SCIO / others).

Build a structured rebuttal with citations (CMS NCCI manuals, AMA CPT guidelines, payor policy, AHA Coding Clinic, contract language as applicable).

Negotiate with audit vendors within delegated authority; escalate to Lead when concession would exceed threshold.

Review patient billing disputes raised through customer service / Patient Financial Services intake.

Reconcile disputed line items against medical record and applicable EOB; produce a patient-readable explanation.

Escalate suspected billing errors for write-off / adjustment per client policy.

Maintain a real-time individual case log (tracking status, turnaround time, $ impact, and outcomes) using standardized taxonomies to support portfolio trend analysis.

Produce reproducible, structured audit reports using standard templates to communicate scope, methodology, line-level results, and root causes to client stakeholders and feed activity reports.

Navigate provider EHR platforms (e.g., Epic, Cerner, Meditech) and specialized auditing software to abstract clinical documentation and support defense workflows.

Operate under HIPAA, HITRUST, and OIG / RAC / MAC awareness; never share PHI outside authorized channels.

Cooperate fully with internal QA on sample audits; respond to QA findings with documented corrective action.

Key Success Indicators/Attributes

High comfort level reading dense clinical records (MAR, operative notes, nursing logs) and cross-referencing against itemized bills to identify root causes.

Confidence and technical writing skills to draft clear audit findings and defend them during payor rebuttal cycles, with the objectivity to overturn findings when evidence shifts.

Clear understanding of how line-item charge adjustments impact gross/net revenue, DRG allowances, and patient billing integrity.

Consistently meets daily turnaround time (TAT) targets without compromising audit accuracy.

Sustained concentration and analytical rigor required to execute multi-hour reviews on complex inpatient, surgical, and high-dollar cases.

Confidentiality and PHI discipline.

Maintain courteous and professional working relationships with employees at all levels of the organization.

Qualifications
This is a full-time position. Each employee’s schedule must be between the hours of 6:00 AM PST to 9 PM PST, Monday through Friday with the specific schedule for each employee to be agreed upon by the employee’s manager and the employee, taking into account the needs of the client. This position occasionally requires long hours and weekend work

Required Education and Experience

3+ years of hands-on US charge audit, DRG audit, or itemized bill review experience in a healthcare provider or vendor environment.

Bachelor’s degree or combination of education and strong revenue cycle auditing tenure.

Active baseline coding credential from AHIMA (CCS) or AAPC (CPC, COC, CIC).

Hands-on experience with at least one major EHR system (Epic Resolute, Cerner Patient Accounting, Meditech, or Athena).

Practical understanding of US payment methodologies and the ability to review payer contracts to verify allowed units and reimbursement rules.

Strong working knowledge of inpatient and outpatient clinical documentation expectations, with proven ability to evaluate operative notes, MARs, and clinical records to substantiate billed CPT/HCPCS/ICD-10 codes.

Working fluency in NCCI, OCE, LCD/NCD guidelines, revenue codes, modifiers, MS-DRG/APR-DRG fundamentals, and OPPS APC.

Preferred Education and Experience

Active AHIMA CPMA credential.

Hands-on exposure to specialized audit platforms (e.g., MD-Audit, EXL, Conifer, or Equian products).

Direct experience defending billed charges and managing ADR workflows under RAC/MAC/OIG frameworks or against major payment integrity vendors.