APC Coding Validation Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Perform thorough assessments to verify the correctness of billed charges against medical documentation, payer policies, coding standards, and industry norms to secure proper reimbursement.

• Implement coding guidelines across a wide variety of outpatient services, including but not limited to Interventional Radiology, Radiation Oncology, injections and infusions, outpatient surgeries, implants, and observation services (including carve-outs).

• Exhibit a solid understanding of outpatient reimbursement methods, including the Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classification (APC), and Enhanced Ambulatory Patient Grouping (EAPG).

• Apply advanced knowledge of NCCI edits, including suitable modifier usage, along with CPT and HCPCS coding guidelines.

• Analyze and apply Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).

• Deliver clear, concise, and defensible audit results that accurately reflect reimbursement impacts.

• Formulate and present well-supported justifications for coding modifications that affect reimbursement, citing appropriate references such as AMA Official Coding Guidelines, CPT Assistant, AHA Coding Clinic, payer policies, and other industry-standard materials.

• Collaborate efficiently both independently and within a team-oriented, production-focused environment.

• Uphold established standards for accuracy, quality, and productivity, ensuring correct code assignment and comprehensive documentation of review results.

• Use computer applications and tools, including Grouper/Pricer software, ICD-10-CM encoders, and Microsoft Office products.

• Comply with the Standards of Ethical Coding as set forth by AHIMA.

• Undertake additional responsibilities as assigned.

⛳️ Requirements

• Associate’s or Bachelor’s degree in Health Information Management, Medical Coding, or a related discipline.

• Minimum of 2 years of experience in conducting pre-pay and/or post-pay reimbursement audits.

• Extensive outpatient facility auditing experience, covering specialty areas such as Interventional Radiology, injections and infusions, Radiation Oncology, Behavioral Health, and ambulatory surgery.

• Active certification such as RHIT, RHIA, CCS (AHIMA), and/or CPC.

• 5-7 years of experience in outpatient facility coding/auditing.

• Strong understanding of ICD-10-PCS/CM, CPT, and HCPCS coding guidelines.

• Background in performing pre- and post-payment reimbursement audits.

• Proficiency in Medicare regulations, including LCDs, NCDs, NCCI edits, OPPS, and APC methodologies.

• Proven experience with APC payment methodologies, OPPS reimbursement logic, fee schedules, and payer contracts.

• Exceptional verbal and written communication abilities.

• Keen attention to detail and strong analytical skills.

• Familiarity with encoder and auditing tools (e.g., 3M, TrueBridge, Grouper/Pricer Software).

🏝️ Benefits

• Work from anywhere in the US! Machinify is digital-first.

• Comprehensive Medical/Dental/Vision offerings.

• FSA/HSA options available.

• Tuition reimbursement program.

• Competitive salary along with a 401(k) that includes company matching.

• Additional health and wellness benefits and perks.

• A flexible and trusting work environment where you’ll feel empowered to perform at your best.