Role Description The QA Auditor performs audit functions across Client Teams to determine operational efficiency, adherence to internal processes and procedures as well as regulatory requirements, and achievement of quality standards. This role requires an in-depth understanding of the denials management process, a clinical background, attention to detail, and the ability to effectively assess the quality of work completed. The QA Auditor will work closely with internal teams to provide feedback, maintain high standards of quality, and ensure compliance with established processes. - Conduct regular audits of work performed by appeal writers and automated processes to ensure adherence to internal policies and quality standards in the denials management process. - Evaluate how denials are handled, ensuring that all necessary steps are followed, documentation is accurate, and appropriate actions are taken. - Identify defects and improve departmental performance by supporting quality, operational efficiency, and production goals. - Offer constructive feedback to appeal writers based on audit results, identifying areas for improvement and providing guidance on corrective actions. - Provide feedback on automated processes to ensure the highest levels of efficiency in overturning denials. - Maintain accurate records of audit findings and track trends or recurring issues in the denials management process. - Prepare reports to share with management and relevant teams. - Develop strategies for business performance improvement initiatives, including identifying opportunities for improvement, problem prioritization, and creating performance improvement plans for non-compliant audits and/or reports. - Utilize and navigate multiple internal systems (e.g., claims processing systems, communication tools) to review audit data and provide feedback. - Adapt to new systems as necessary. - Work closely with appeal writers, managers, and other stakeholders to foster a collaborative approach to quality improvement and process optimization. - Additional duties as assigned. - Use, protect, and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards. - Understand and comply with Information Security and HIPAA policies and procedures at all times. - Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties. Qualifications - State Licensed RN is required. - Experience working in a healthcare or insurance environment, particularly with claims and denials management. - Familiarity with common claims management and denial resolution systems. - Experience in quality auditing or process improvement initiatives. - Familiarity with MCG and Interqual guidelines and processes. - Strong understanding of the denials management process, including common causes of denials and strategies for resolution. - Prior experience with medical records review, claims processing, utilization/case management in a clinical practice or managed care organization, Clinical Appeal Writer, etc. - Advanced knowledge of Microsoft Word, Excel, and Teams for communication, data analysis, and reporting. - Ability to quickly learn and effectively navigate multiple software systems, providing accurate and timely feedback. - Strong analytical skills with the ability to detect issues, inconsistencies, and areas for improvement in the denials management process. - Ability to manage multiple audits simultaneously while maintaining accuracy and efficiency. - Strong interpersonal skills, ability to communicate well at all levels of the organization. - Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses. - High level of integrity and dependability with a strong sense of urgency and results oriented. - Excellent written and verbal communication skills required. - Gracious and welcoming personality for customer service interaction. Working Conditions - Ability to travel to client sites on occasion. - Ability to work outside of normal business hours as needed. Physical Demands - While performing the duties of this job, the employee is occasionally required to move around the work area; sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals, and telephones; extend arms; kneel; talk and hear. Mental Demands - The employee must be able to follow directions, collaborate with others, and handle stress. Work Environment - The noise level in the work environment is usually minimal.

Role Description J2 Integrity Solutions is seeking a Professional Coder/Auditor to support client engagements through a blended role that pivots between coding production and coding audit responsibilities. This position is ideal for a high-performing professional coder who is equally confident performing accurate and timely coding while also evaluating documentation and coding quality through structured audit reviews. The Professional Coder & Auditor will serve as a subject matter expert in ICD-10-CM, CPT, HCPCS, modifiers, and applicable CMS and payer-specific requirements. This role plays a key part in ensuring accurate billing, supporting revenue integrity, reducing compliance risk, and identifying education opportunities that strengthen documentation and coding performance. In addition to day-to-day coding and auditing work, this position will contribute to the development of educational tools and training materials to promote coding best practices and continuous improvement. The ideal candidate is detail-oriented, efficient, highly analytical, and able to pivot seamlessly between productivity-driven coding responsibilities and quality-focused audit work. Key Responsibilities - Pivot between production coding and audit responsibilities based on client needs and internal priorities. - Perform accurate, timely professional fee coding across assigned specialties and services, meeting defined productivity and quality benchmarks. - Assign appropriate ICD-10-CM, E/M, CPT, HCPCS, and modifiers in accordance with official guidelines and client-specific policies. - Ensure coding aligns with CMS, AMA, payer-specific policies, and NCCI edits to support clean claims and denials prevention. - Meet defined productivity and turnaround time expectations while maintaining high quality standards. - Conduct structured audits of coded encounters to validate coding accuracy, documentation integrity, and compliance. - Audit and validate E/M leveling using current CMS/AMA guidelines, including time and complexity-based models. - Identify under coding, over coding, missed charges, risk-adjustment and HCC opportunities, compliance risk, and revenue opportunities. - Document audit findings with clear rationale, applicable guideline references, and recommended actions. - Provide respectful, constructive feedback to coders, providers, and stakeholders, including navigating difficult conversations when needed. - Identify trends, root causes, and recurring patterns impacting coding quality and documentation, and translate them into practical education and process recommendations. - Develop tip sheets, SOPs, job aids, and training tools to promote coding consistency and best practices. - Deliver targeted data-driven education and coaching based on audit findings and performance gaps. - Collaborate with Coding, CDI, Revenue Integrity, and Compliance teams to support denial prevention, revenue protection, and accurate quality reporting. - Serve as a professional representative and brand ambassador of J2 Integrity Solutions, modeling integrity, and client-focused problem solving. - Roll up your sleeves to assist with the day-to-day support needed. Create internal policies, procedures, and work efforts at J2. - Other duties as assigned. Qualifications - Certification: CCS, CCS-P, CPC, RHIT, RHIA, CPMA, or equivalent required. - Experience: 3+ years of multi-specialty professional fee coding experience, including E&M. 2+ years of professional coding audit experience strongly preferred. Prior experience in a consulting or multi-client environment is a plus. - Technical Proficiency: Experience with EHR and encoders. Epic preferred. - Industry Knowledge: Deep understanding of ICD-10-CM, CPT, HCPCS, HCC, modifier application, CMS and AMA documentation standards, NCCI edits and payer-specific requirements, and risk adjustment methodologies. - Skills: Strong written and verbal communication skills, including the ability to deliver feedback clearly and confidently. Ability to work independently in a remote environment, manage competing priorities, and pivot between coding production and audit responsibilities based on client needs. High degree of accountability, integrity, and follow-through in meeting deadlines and delivering quality work. Ability to use data (dashboards, spreadsheets, and metrics) to track trends and outcomes of audits and education. Benefits - At J2 Integrity Solutions, we are committed to excellence, integrity, and innovation in healthcare coding and compliance. - As part of our team, you will have the opportunity to drive meaningful changes, support diverse clients, and be part of a dynamic team of professionals.

• Serve as an audit team member for a health plan(s) which currently administers benefits to Medicaid members across multiple lines of business including acute, behavioral health, individuals with developmental disabilities, and children in out-of-home care. • Audit records on a routine basis, as well as records for audits (requested on an ad hoc basis) for all lines of business, in order to ensure coding and documentation meet regulatory standards. • Coordinate audit documentation and reports for review for internal and external staff and stakeholders. • Identify aberrant billing patterns and potential FWA, reporting this to internal staff. • Assisting with further investigation and/or reports to state regulators through the utilization of developed critical thinking skills. • Assist with the development and implementation plan for prospective and retrospective FWA avoidance, detection, and referral. • Assist with the creation and submission of regulator deliverables through completion of timely audit activities. • Provide technical assistance and education to providers including training on regulatory requirements, as well as coding and documentation rules. • Maintain compliance with company policies and procedures. • Perform other duties as assigned.

Role Description We are looking for a Senior Field Premium Auditor to support our Southern California territory. This individual will work fully remote in this territory with the ability to travel within local metropolitan areas, specifically in Los Angeles County. - Conducts thorough audits of insureds financial records to verify the accuracy of reported premiums, ensuring that all calculations are precise and compliant with company policies, industry regulations, and legal requirements. - Reviews and analyzes moderately complex financial statements, payroll records, and other relevant documents. - Identifies and resolves complex discrepancies in policyholder records by collaborating with producers, underwriters, insureds, leadership, and other internal departments, ensuring that all issues are addressed promptly and effectively. - Reviews and determines the applicability of insurance certificates and class codes to specific exposures. - Reviews claim activity on policies to ensure that employee coding is consistent and accurate. - Prepares and presents detailed audit reports to management, providing clear and actionable findings that support informed decision-making. - Collaborates with underwriters and other internal departments to ensure accurate premium calculations. - Provides excellent customer service to policyholders by addressing any audit-related inquiries and ensuring a positive experience throughout the audit process. - Performs other duties as assigned. Qualifications - Bachelor’s degree in Math, Accounting, Finance, Business, Risk Management and Insurance, or a related field or equivalent experience. - Generally, a minimum of 3-7 years of experience in Premium Audit. - Demonstrates strong analytical and problem-solving skills. - Demonstrates excellent interpersonal and communication skills, with the ability to work collaboratively in a fast-paced environment and across departments. - Requires frequent travel by car. Company vehicle is included. Benefits - Competitive benefits packages for full-time and part-time employees. - Full-time employees have access to medical, dental, and vision coverage, wellness plans, parental leave, adoption assistance, and tuition reimbursement. - Paid Time Off and paid holidays for full-time and eligible part-time employees. - 401(k) plan with company match. - Employee stock purchase plan. - Commuter benefits. Company Description For over 50 years, Republic Indemnity has been a trusted partner for businesses across the western U.S., helping them effectively manage their workers' compensation costs. Our headquarters in Woodland Hills, California, along with our office in San Francisco, serve as hubs for our operations. We specialize in workers' compensation primarily in California, with business presence in Alaska, and other western states. At Republic, we believe in creating clear pathways for everyone - whether it's a broker, policyholder, injured worker, or colleague. We're committed to helping people reach their goals and achieve success.