Healthcare Auditor & Coding Consultant, Forensics and Compliance

What You'll Do: Review medical records, claims, charge detail, billing data, reimbursement data, policies, and contracts for accuracy, support, and compliance. Audit ICD-10-CM, ICD-10-PCS, CPT, HCPCS Level II, modifiers, units, revenue codes, and related coding requirements across facility and professional settings. Evaluate MS-DRG, APR-DRG, APC, ASC, and professional fee reimbursement methodologies, including Medicare, Medicaid, commercial, and payor-specific rules. Assess clinical documentation, medical necessity, level of care, patient status, utilization review, coverage, and clinical-to-code alignment. Analyze the end-to-end revenue cycle and claims lifecycle, including charge capture, coding, billing, claims submission and adjudication, denials, appeals, recoupments, collections, and patient responsibility. Review health plan provider contracts, reimbursement terms, coverage policies, claims processing practices, and payment determinations. Plan and conduct risk-based audits, investigations, and forensic analyses; identify patterns, outliers, root causes, and potential overpayments or underpayments. Develop clear, reproducible workpapers, calculations, findings, and recommendations that support defensible conclusions. Prepare reports and client-ready deliverables and support regulatory responses, disputes, expert reports, depositions, or testimony as needed. Collaborate with clients, legal counsel, clinicians, coding and billing teams, health plan personnel, and engagement teams; provide technical guidance and support consistent audit practices.

What You'll Bring: Bachelor's degree in Health Information Management, nursing, healthcare administration, business, or a related field, or an equivalent combination of education and experience.5-10+ years of progressively responsible experience in healthcare coding, billing, auditing, reimbursement, revenue cycle, payment integrity, or claims operations. Demonstrated hands-on experience with inpatient facility, outpatient facility, ASC, and professional fee coding, billing, auditing, and reimbursement. One or more active coding, auditing, billing, or HIM credentials preferred, such as CCS, CIC, CPC, COC, CPMA, CHCA/CHCAF, CPB, RHIT, RHIA, or a comparable credential. Advanced knowledge of applicable coding guidelines, reimbursement methodologies, payor policies, CMS requirements, HIPAA, the False Claims Act, and healthcare compliance principles. Proven ability to analyze complex medical records and claims data, manage audit work, document methodology, and communicate findings clearly in writing and verbally. An active RN license, another clinical credential, or substantial clinical experience is preferred. Prior experience as an HIM director or in comparable HIM, coding, clinical documentation, revenue integrity, or compliance leadership is preferred. Health plan contracting experience involving provider agreements and reimbursement terms is preferred. Health plan claims processing or adjudication experience, including payment integrity, coverage policy, denials, appeals, or recoupments, is preferred; litigation consulting or expert witness support experience is also valued.

How You'll Thrive: Integrate clinical, coding, operational, contractual, and payor perspectives to solve complex healthcare problems. Exercise sound judgment, objectivity, discretion, and attention to detail while managing multiple priorities and deadlines. Communicate technical concepts clearly to clinical, operational, executive, regulatory, and legal audiences. Take ownership, collaborate effectively, mentor others, and consistently deliver high-quality work. Demonstrate integrity and embody Stout's core values: Positive and Team-Oriented, Accountable, Committed, Relationship-Focused, Super-Responsive, and Great Communicators while delivering Relentless Excellence. Why Stout? At Stout, we offer a comprehensive Total Rewards program with competitive compensation, benefits, and wellness options tailored to support employees at every stage of life. We foster a culture of inclusion and respect, embracing diverse perspectives and experiences to drive innovation and success. Our leadership is committed to inclusion and belonging across the organization and in the communities we serve. We invest in professional growth through ongoing training, mentorship, employee resource groups, and clear performance feedback, ensuring our employees are supported in achieving their career goals. Stout provides flexible work schedules and a discretionary time off policy to promote work-life balance and help employees lead fulfilling lives. Learn more about our benefits and commitment to your success. The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements and criteria necessary to successfully perform the job. Stout is an Equal Employment Opportunity. All qualified applicants will receive consideration for employment on the basis of valid job requirements, qualifications and merit without regard to race, color, religion, sex, national origin, disability, age, protected veteran status or any other characteristic protected by applicable local, state or federal law. Stout is required by applicable state and local laws to include a reasonable estimate of the compensation range for this role. The range for this role considers several factors including but not limited to prior work and industry experience, education level, and unique skills. The disclosed range estimate has not been adjusted for any applicable geographic differential associated with the location at which the position may be filled. It is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is $74,000.00 - $135,000.00 Annual. This role is also anticipated to be eligible to participate in an annual bonus plan. Information about benefits can be found here - https://www.stout.com/en/careers/benefits.SummaryLocation: Chicago, IL; Arlington, VA; Cleveland, OH; Grand Rapids, MI; Detroit, MI; Baltimore, MD; Washington, DC; Tysons Corner, VA

Type: Full time