Claim Review Specialist – Facility Coding, Certification Required

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

📋 Description

• Support the Director of HIM in executing claim audits.

• Evaluate and suggest improvements for coding, revenue cycle, and billing practices for client hospital outpatient and Profee claims using proprietary software.

• Create standardized reports utilizing the software.

• Engage with clients and address coding inquiries in clear, concise, and grammatically correct English.

• Provide assistance to fellow revenue cycle consulting team members.

• Prepare educational materials for clients and write FAQ responses.

• Achieve proficiency in the PARA Data Editor proprietary software.

• Select and analyze claims based on trends and data assessment; arrange medical documentation accordingly.

• Conduct audits on charges, OPPS and CAH charges, CMS/payer guidelines, ICD-10-CM and CPT/HCPCS coding, departmental data/documentation, NCCI/MUE edits, Medi-Cal and Medicare guidelines, units of service, E/M Profee/facility coding, and documentation enhancement.

• Assist in creating written documents for publication, including Q&A entries.

• Gain a comprehensive understanding of outpatient hospital reimbursement, documentation, coding, and billing processes.

• Partake in presentations to clients and potential clients through web meetings.

• Keep up-to-date with specialty knowledge, certifications, and accreditations; research new guidelines, data elements, and payer specifications.

• Perform additional tasks as assigned.

⛳️ Requirements

• Coding certification from AHIMA or AAPC is mandatory; CCS, COC, or CPC certification is required (CPC-A is not accepted).

• Minimum of 5 years of relevant, hands-on experience in outpatient facility coding.

• Extensive experience in OP facility coding, including ED, SDS, I&I, OBS, facility E/M, ancillary, IR, and Profee coding.

• Experience in IP facility coding is advantageous.

• Familiarity with Critical Access settings is preferred.

• Knowledge of medical terminology and anatomy is essential.

• Strong grasp of revenue cycle, CMS Manual/guidelines, Medicaid guidelines, Official Coding Guidelines, and outpatient coding and billing practices.

• Understanding of revenue codes, HCPCS, MUE and CCI/NCCI edits, units of service, and ICD-10-CM.

• Proficient in Microsoft Excel, PowerPoint, Word, and OneNote.

• Strong analytical skills, independent thinking, and decision-making capabilities.

• Exceptional written and verbal communication and presentation abilities.

• Solid computer and technology skills.

• Highly professional demeanor with a focus on client satisfaction.

• Ability to work at a computer terminal for 6–8 hours daily.

• Capability to lift and carry materials weighing up to 20 lbs. as needed.

🏝️ Benefits

• Investment in professional development and personal growth.

• Opportunity to work from home.

• Flexible remote work arrangement.