Clinical Documentation & Claims Compliance Specialist

Preventive Measures • Washington, DC

8d

About The Position

The Clinical Documentation & Claims Compliance Specialist is responsible for reviewing clinical documentation and billing data to ensure services meet payer requirements and organizational compliance standards. This role supports the Billing Department by verifying authorizations, documentation accuracy, and claim readiness prior to submission. The specialist conducts quality assurance reviews to identify documentation deficiencies, authorization issues, and billing errors that may result in claim denials. This position works collaboratively with clinical staff, billing teams, and leadership to ensure accurate claim submission, minimize denials, and maintain compliance with Medicaid and payer regulations, including DC Medicaid billing requirements.

Requirements

• Understanding of CPT, ICD-10, and healthcare billing practices.
• Knowledge of Medicaid billing requirements and payer compliance rules.
• Strong attention to detail and analytical skills.
• Proficiency in Excel for tracking and reporting.
• Ability to work independently while collaborating with clinical and billing teams.
• Associate’s or Bachelor’s degree in healthcare administration, Health Information
• Management, Business Administration, or a related field preferred.
• 2+ years of experience in healthcare billing, clinical documentation review, or revenue
• cycle operations.
• Experience with Medicaid billing and authorization processes preferred.
• Experience working with electronic health record (EHR) systems.

Nice To Haves

• Experience with Medicaid billing and authorization processes preferred.

Responsibilities

• Verify documentation supports billed CPT codes and services rendered.
• Review clinical documentation to ensure services meet payer billing requirements.
• Identify incomplete, late, or non-compliant documentation prior to billing.
• Perform quality assurance reviews of claims to ensure accuracy prior to submission.
• Confirm correct CPT codes, modifiers, diagnosis codes, and rendering provider information.
• Verify authorization numbers and service approvals in payer portals prior to billing.
• Ensure services billed align with approved authorizations and service limits.
• Analyze denied claims to identify root causes related to documentation or billing errors.
• Monitor denial trends and recommend corrective actions.
• Maintain tracking logs for documentation reviews, authorizations, and claim errors.
• Prepare weekly or monthly reports summarizing QA findings and trends.
• Assist with internal compliance reviews and audit preparation.
• Provide feedback to clinical staff on documentation requirements and compliance standards.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree