Claim Review Specialist - Coding Certification Required

About Us

We are dedicated to helping our clients surpass their financial health objectives. Through the entire reimbursement cycle, we offer scalable solutions and clinical expertise to address programmatic challenges. Our teams are empowered with cutting-edge technology, enabling data-driven solutions that ensure accountability in achieving goals. We emphasize long-term career development by investing in our employees, fostering an environment conducive to both professional and personal growth.

Job Summary

This position assists the Director of Health Information Management (HIM) in preparing claim audits, reviewing, and recommending coding and billing adjustments on outpatient and professional fee claims for client hospitals. Utilizing proprietary software, the role involves generating standardized reports, client interactions to clarify coding queries, and supporting the revenue cycle consulting team. Additional duties include client education and preparing written FAQs.

Qualifications and Requirements

• Possess a recognized coding certification through AHIMA or AAPC (CPC-A not accepted).
• Over five years of extensive experience in outpatient facility coding, including emergency department (ED), same-day surgery (SDS), inpatient and intensive (I&I), observation (OBS), evaluation and management (E/M) for facilities, among others.
• Experience in inpatient facility coding and critical access settings is advantageous.
• Solid understanding of medical terminology, anatomy, revenue cycle processes, and CMS/Medicaid guidelines.
• Proficiency with official coding guidelines, including outpatient coding and billing concepts (revenue codes, HCPCS, MUE, CCI edits, units of service, ICD-10-CM).
• Strong skills in Microsoft Excel, PowerPoint, Word, and OneNote.
• Excellent analytical abilities, independent critical thinking, decision-making, and communication skills are essential.
• Professional demeanor and client service orientation required.

Responsibilities

• Master the PARA Data Editor, a proprietary software tool.
• Select claims for review based on data trends, organize claim and documentation information thoroughly.
• Conduct detailed audits assessing omitted or inaccurate charges, outpatient prospective payment system (OPPS), critical access hospital (CAH) charges, and compliance with CMS/payer specific rules.
• Review coding accuracy for ICD-10-CM and CPT/HCPCS codes (including ranges like 10000-69999, 80000, 90000, J/G/Q codes).
• Evaluate departmental data for missing or incorrect info and charges.
• Apply edits such as NCCI, MUE, Medi-Cal, and Medicare guidelines.
• Verify units of service for evaluations and other billing components, including both professional fee and facility billing.
• Contribute to documentation improvements and prepare written materials under director guidance.
• Engage in client and prospective client presentations, mostly through web meetings.
• Continually update expertise in outpatient hospital reimbursement processes and related specialty areas.
• Maintain certifications and continuously research new guidelines, data requirements, and payer policies.
• Perform other job-related tasks as assigned.

Additional Information

Position reports directly to the Director of HIM/Audit Services within RCM Services.
Remote work based in the United States is required.
Employment status is full-time and exempt.
Physical requirements include prolonged computer usage (6-8 hours daily), regular manual dexterity, occasional lifting up to 20 pounds, and ability to manage stress during peak workload periods.
The job description is a guideline for essential responsibilities and is not exhaustive; duties may be adjusted by supervision as necessary.