Senior Clincial Specialist - Revenue Integrity

About the role

SunStone Consulting helps healthcare organizations navigate reimbursement, regulatory, compliance, and revenue cycle challenges. We assist hospitals, health systems, physician practices, and other providers. This role requires a clinical specialist with extensive experience in documentation, coding, and billing audits.

Responsibilities

• Develop audit approaches aligned with each client’s needs.
• Provide clinical oversight and coding support during documentation, coding, and billing reviews.
• Conduct quality reviews of consultant findings and prepare clear, referenced observations and recommendations.
• Evaluate governmental and third-party payer denials using relevant guidelines.
• Translate complex regulatory resources into client-friendly summaries.
• Prepare accurate, clinically credible work papers supporting audit findings.
• Deliver education on documentation and coding improvement opportunities to practitioners, clinical staff, allied health professionals, and coders.

Requirements

• Bachelor of Science in Nursing (BSN) and/or active RN license (other clinical degrees considered).
• At least one coding certification: CPC, COC, CCS, or CCA.
• 10+ years of multi-entity clinical, coding, or health information experience.
• Strong clinical knowledge of anatomy, physiology, and medical terminology.
• Excellent communication skills and ability to collaborate effectively.
• Independent judgment, analytical thinking, accuracy, and strong decision-making abilities.
• Proficiency with Microsoft Word, Excel, and email applications.

Qualifications

• Experience with Medicare/Medicaid regulations, Conditions of Participation, state healthcare rules, ICD-10-CM and CPT guidelines, AMA E/M guidance, NCCI edits, Coding Clinics, and other regulatory resources.

Skills

• Strong clinical knowledge of anatomy, physiology, and medical terminology.
• Excellent communication skills and collaboration abilities.
• Independent judgment, analytical thinking, accuracy, and strong decision-making abilities.
• Proficiency with Microsoft Word, Excel, and email applications.

Benefits

• A culture built on transparency, teamwork, and professional growth.
• The autonomy to work independently while being supported by a highly skilled, collaborative team.
• Opportunities to expand expertise across diverse client engagements.
• The chance to influence documentation quality and compliance at a meaningful scale.