Goodroot is a community of companies committed to delivering more access to better healthcare at a lower cost. With a growing group of brands including, but not limited to AlignRx, Coeo, and Sola, Goodroot is reshaping healthcare for good, one system at a time. Our growing products and services portfolio includes pharmacy benefit consulting, pharmacy benefit coalition, health plan options for self-funded employer groups, patient navigation, and hospital financial assistance consulting. Learn more at www.goodrootinc.com. Goodroot is an Equal Opportunity Employer.

Penstock is an affiliate company of Goodroot and was just recently named Best Place to Work by Buffalo Business Journal. Penstock is a service partner and SaaS builder for forward-thinking health plans and providers, empowering recovery, audit, and regulatory teams to get the accuracy right from the start—when it matters most. Our mission is to create lasting systemic change that removes wasted spend from our healthcare system, returning dollars to payers, lowering the cost of care, and improving access for all. Our business model is rooted in transparency and the drive to reinstate true integrity in payment integrity—even if it defies traditional business sense. We geek out over building and perfecting software that helps health plans succeed, but we also understand the irreplaceable value of human intelligence.

Role and Responsibilities

The Senior Clinical Auditor is a seasoned leader on the Penstock Audit team, responsible for ensuring that outpatient and professional services are clinically valid and/or medically necessary, and are billed in accordance with applicable policies, guidelines, and industry-recognized standards of care. The Senior Clinical Auditor embodies the standards of honesty, excellence, and innovation central to the Penstock mission, and serves as a resource and mentor for other Audit Team members.

• Conducts thorough, thoughtful reviews of healthcare claims and medical records, and applies clinical judgment to identify inappropriate payments and improper billing practices
• Identifies and refers scenarios that require input from a coding auditor
• Writes thorough, accurate, and well-documented rationale to support audit determinations, citing appropriate guidelines, policies, regulations, and/or standards
• Prepares written responses and/or participates in conference calls regarding payor or provider questions about Penstock audit findings
• Supports the ongoing Penstock mission of improving healthcare reimbursement by highlighting possible provider training needs and helping prepare and/or conduct education sessions on potentially sensitive topics
• Helps analyze audit results to identify opportunities for edit refinement and/or internal training
• Participates in training and development of new audit opportunities across a myriad of clinical and coding scenarios
• Keeps abreast of clinical, regulatory, and other industry changes that impact Penstock auditing and/or that suggest new audit opportunities
• Participates in keeping the Clinical Audit team informed of industry changes that impact auditing
• Contributes to the creation and maintenance of the Penstock Clinical Parameters library
• Maintains focus on the identification and development of new audit concepts
• Continuously considers the systems and processes involved with healthcare reimbursement (both internal and external) and communicates ideas for improvement through appropriate channels
• Communicates kindly, professionally, and effectively with all customers, both internal and external, and refers issues to management as appropriate
• Continuously strives to find new avenues for fulfilling the Penstock mission of reclaiming greater integrity between payors and providers
• Serves as a Payment Integrity subject matter expert for Penstock team members and for the Goodroot organization as a whole
• Meets or exceeds Penstock’s performance and quality standards.

• Minimum of an Associate degree
• Active Registered Nurse (RN) license
• 5 or more years of clinical experience in a healthcare facility setting
• Recent experience auditing health insurance claims for improper payments
• Familiarity with government and commercial billing rules and payment methods
• Familiarity with Inter-Qual and Milliman Care Guidelines (MCG) clinical criteria sets
• Awareness of and adherence to HIPAA, and all laws regarding the safeguarding of PHI/PII
• Ability to conduct independent research using credible sources
• Demonstrated working knowledge of Microsoft Word, Excel, and PowerPoint
• Ability to apply critical thinking skills to record reviews
• Ability to work independently, manage workload, and adapt to shifting priorities
• Willingness to adapt and learn new auditing skills across a myriad of clinical and coding scenarios
• Excellent communication skills, both oral and written
• Comfortable working in an ever-changing environment
• Able to work Eastern time zone hours
• Secure and private home office with reliable high-speed internet connection

Preferred Skills

• Bachelor’s degree
• 7+ years of relevant auditing and/or coding experience
• AHIMA/AAPC Coding Certification (RHIA, RHIT, CCS, CPC, CPC-H)
• Clinical Documentation Integrity experience
• Intermediate or expert-level Excel skills