Outpatient Payment Integrity Production Coder

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

📋 Description

• Conduct outpatient coding reviews utilizing medical records, itemized bills, claim lines, payer requirements, CPT/HCPCS guidelines, ICD-10-CM standards, revenue codes, modifier regulations, NCCI edits, APC/EAPG logic, and supporting documentation.

• Assess whether billed outpatient services are substantiated by documentation and ensure accurate reporting of procedure codes, modifiers, units, revenue codes, and billing combinations.

• Detect coding discrepancies, unsupported services, unbundling issues, inappropriate modifier applications, incorrect procedure code selections, unit inaccuracies, documentation shortcomings, and other outpatient payment integrity concerns.

• Consistently implement approved audit target guidance, job aids, payer policies, coding hierarchy, and documentation standards across assigned claims.

• Clearly and defensibly document audit rationale, including findings, code modifications, modifier concerns, documentation gaps, and supporting references.

• Achieve production, quality, turnaround time, and professional standards while ensuring accuracy and consistency.

• Raise complex questions regarding coding, payer policies, reimbursement, pricing, workflow, or documentation to the relevant lead, manager, or subject matter expert.

• Engage in training sessions, calibration reviews, quality feedback discussions, and target refreshers.

• Stay updated on outpatient coding guidelines, payer policies, CMS directives, NCCI edits, LCDs/NCDs, modifier requirements, and reimbursement methodologies.

• Complete assigned claims following approved workflows, target guidance, quality standards, and turnaround expectations.

• Keep accurate notes, take part in quality review and calibration activities, and respond to feedback in a professional manner.

• Comply with company policies, client needs, confidentiality standards, HIPAA regulations, coding compliance expectations, and professional standards.

⛳️ Requirements

• A valid, non-expired coding certification credential is required: CPC, COC, CCS, RHIT, RHIA, or equivalent.

• At least 3 years of outpatient coding experience is required.

• In-depth knowledge of CPT, HCPCS, ICD-10-CM, revenue codes, modifier usage, NCCI edits, outpatient documentation standards, and payer-specific coding requirements.

• Experience in reviewing outpatient facility claims, medical records, operative reports, emergency department records, observation records, ancillary services, injections and infusions, surgical procedures, or other outpatient service lines.

• Capability to interpret payer policies, CMS guidance, LCDs/NCDs, coding references, and documentation requirements and apply them to claim-level reviews.

• Ability to differentiate between coding validation and payment integrity auditing.

• Strong written communication skills, with the ability to document clear, concise, and defensible audit rationales.

• Exceptional attention to detail, analytical thinking, sound judgment, and the ability to work independently in a production setting.

• Ability to meet productivity and quality benchmarks while managing multiple claims, priorities, and deadlines.

• Proficiency in Microsoft Outlook, Word, Excel, coding tools, claim review platforms, and electronic medical record documentation systems.

• Previous experience in payment integrity, audits, outpatient facility audits, payer reviews, or claims reviews is preferred.

• Familiarity with APC, EAPG, OPPS, multiple procedure reductions, packaging, bundling, and payer-specific reimbursement rules.

• Experience using coding references, encoder tools, 3M, TruCode, WebStrat, payer portals, claim systems, or similar applications.

• Experience with Optum platforms.

🏝️ Benefits

• Comprehensive health insurance plans.

• Competitive salary and performance-based bonuses.

• Opportunities for professional development and training.

• Flexible work hours and remote working options.