Medical Reimbursement Coding Specialist

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

📋 Description

• Evaluate intricate, high-value, or contested medical bills, including those related to trauma and inpatient care.

• Perform routine quality control checks on reports.

• Oversee and enhance Medical Bill Review software, workflows, auto-adjudication rules, and engine logic.

• Utilize knowledge of national repricing systems and payer guidelines.

• Ensure accurate implementation of fee schedules, line-item audits, CCI edits, and clinical validation rules across commercial, auto/PIP, and workers’ compensation sectors.

• Conduct thorough forensic examinations of medical records, itemized bills, and payment ledgers for litigation purposes.

• Draft legally defensible expert reports regarding billing precision, unbundling, upcoding, and phantom charges.

• Convert CPT, ICD-10, HCPCS, and DRG coding systems into layman's terms for attorneys.

• Act as a Subject Matter Expert and Expert Witness in legal matters.

• Offer forensic billing analyses, affidavits, deposition testimony, and trial testimony.

• Assist attorneys and Legal Services with billing inquiries and case documentation.

• Identify excessive, unsupported, duplicate, or incorrectly billed charges.

• Assess reasonable reimbursement amounts and defend findings during litigation.

• Recognize opportunities to enhance software functionality, workflows, accuracy, efficiency, and quality standards.

• Maintain a consistent production workload of complex medical bill reviews.

⛳️ Requirements

• An active industry certification is mandatory (e.g., CPC, CCS).

• Experience with Fee schedule UCRs / Benchmark surveys.

• Strong critical thinking capabilities and independent case evaluation skills.

• Ability to interpret complex instructions, identify risks, and determine suitable escalation steps.

• Excellent organizational, prioritization, time management, and follow-through abilities in a high-volume, deadline-driven environment.

• Familiarity with clinical and legal review workflows, expert credentials, report quality expectations, and company service lines.

• Capacity to coordinate effectively with clients, physicians, attorneys, adjusters, Sales, Operations, Management, and Finance.

• Proficient in computer literacy and typing skills.

• Extensive hands-on experience in Medical Bill Review.

• Proven experience in providing legal services, expert witness reports, or trial testimony related to medical bill reasonableness and UCR value analysis.

• Advanced proficiency in major industry-standard bill review platforms (e.g., Conduent/StrataCare, Mitchell/Enlyte, Medata, CompIQ, or similar).

• Preference for candidates based in Texas, or those with substantial experience testifying specifically within the Texas court system and applying Texas statutory fee schedules.

• Preferred ability to detect subtle patterns of healthcare fraud, waste, abuse, or systemic billing irregularities.

• Preferred composed and articulate communication style with professionalism under examination or expert testimony pressure.

• 2–4+ years of experience in customer service, account management, customer success, insurance operations, healthcare operations, or another client-facing operational environment.

• Business experience in a healthcare and/or insurance setting is preferred.

• Strong communication skills, professional judgment, discretion, relationship-building, and conflict-resolution abilities.

• Ability to learn and maintain precise records in company systems.

• Must provide and maintain own internet services.

• An uninterrupted internet connection is essential for this work-from-home role.

🏝️ Benefits

• Medical, dental, and vision coverage for employees and their families.

• Optional life insurance for employees, spouses, and children.

• Plans for hospital indemnity, critical illness, accident indemnity, and pet insurance.

• Basic life insurance provided at no cost.

• Short-term disability coverage at no cost.

• Long-term disability coverage at no cost.

• Generous paid time off policy.

• 401(k) plan with company matching contributions.

• Apple equipment provided for remote workspaces.

• Media stipend available for remote workspaces.

• Collaborative culture in a remote work environment.

• Opportunities for professional growth.

• Comprehensive benefits package.

• Commitment to employee development.