Sr Medical Coding Specialist

Claritev•Bedford, MA

5d•$85 - $95

About The Position

The Senior Medical Coding Specialist provides analysis of the highest dollar and most complex claims by applying research, coding standards, industry knowledge and federal regulations to ensure correct billing practices. In this role, the incumbent will perform reviews to identify variations from quality billing practices and monitor bills for accuracy and compliance. This position also requires familiarity with international coding systems and healthcare billing practices to support global operations and ensure alignment with international standards.

Requirements

Current coding certification through AHIMA or AAPC, or medical license such as RN or MD, required
7+ years of experience in a clinically related field including, but not limited to, coding, auditing, nursing, radiology, laboratory, pharmacy, or physician assistant roles
Extensive knowledge of inpatient and outpatient hospital billing and claims data, including UB-04s, revenue codes, CPT, HCPCS, ICD-10, DRG, APCs, and familiarity with international equivalents such as KSA, ICD-10-AM, ACHI, and CCI
Extensive knowledge of international medical coding and data resources such as WHO guidelines, CPT Assistant, medical association publications, and clinical research websites supporting medical coding is required
Knowledge of payer reimbursement policies, state and federal regulations, medical necessity criteria, and applicable industry standards
Auditing and health information management experience in a healthcare setting preferred
Experience and proficiency using Microsoft Office Suite, including Excel, Outlook, and PowerPoint; Visio helpful; experience with international billing platforms is a plus
Excellent written, verbal, and listening communication skills, along with strong interpersonal, organizational, time management, analytical, problem-solving, troubleshooting, and customer service skills, including cross-cultural communication
Ability to develop educational materials and job aids pertaining to coding and claims
Ability to work evening or weekend hours as needed to meet deadlines
Ability to handle multiple tasks in a fast-paced environment
Ability to meet individual and team goals, deadlines, and work standards
Ability to apply independent judgment and determine the appropriate course of action
Ability to read and abstract medical records
Extensive knowledge of medical terminology, anatomy, and physiology
Ability to lead, teach, mentor others, and facilitate a learning environment
Individual in this position must be able to work in a standard office environment, which requires sitting and viewing monitor(s) for extended periods of time and operating standard office equipment such as a keyboard, copier, and telephone

Nice To Haves

Auditing and health information management experience in a healthcare setting preferred
Experience and proficiency using Microsoft Office Suite, including Excel, Outlook, and PowerPoint; Visio helpful; experience with international billing platforms is a plus

Responsibilities

Review and analyze complex inpatient, outpatient, and practitioner billing for medical appropriateness of treatment; analyze charges of various revenue centers with consideration to patient diagnosis, procedures, age and facility type and international healthcare norms where applicable
Assist management in the daily operations and processes within the department.
Design and participate in the clinical and coding education of coders, negotiators, and physicians, incorporating international coding systems (e.g., ICD-10-AM, OPCS-4, SNOMED CT). This includes orientation, training and mentoring of new and existing staff.
Facilitate daily claim completion meetings with coding operations teams, including international counterparts when applicable; discuss complex cases, provide feedback, and initiate new coding protocols.
Drive successful coding operations through the application of learned, certified knowledge in addition to continuous professional development and ongoing coding research.
Provide general support to clinical team members, serving as a resource and subject matter expert (SME).
Monitors turnaround times for multiple applications and provides suggestions for process efficiencies.
Uses independent decision making skills to review claims after business hours to meet deadlines.
Apply national and international coding standards and regulations to claims billed.
Research and review individual claims, claim trends or detailed itemized bills, operative notes and other documentation as needed.
Collaborate with physician and analytics teams to create, enhance or suggest new coding edits, claim factors, guidelines and other applicable reference materials.
Monitor, research, and summarize trends, coding practices, and regulatory changes.
Apply clinical judgment and high level of expertise along with analytic skills in review of the most challenging and difficult cases; including conducting additional research as needed.
Communicates clinical, coding and reimbursement findings to co-workers and management in a clear, organized manner.
Evaluate performance of both newly hired and existing staff. .
Assist with education of staff as it relates to claims, suggest additional negotiation talking points or tools, develop instructional design, when applicable and communicate overall industry or regulatory changes which affect the department.
Partner with management to drive department goals and objectives.
Collaborate, coordinate, and communicate across disciplines and departments, and international teams.
Ensure compliance with HIPAA regulations and international data protection regulations (e.g., GDPR, PIPEDA).
Demonstrate commitment to the Company's core values.
Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.
The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

Benefits

Medical, dental and vision coverage with low deductible & copay
Life insurance
Short and long-term disability
Paid Parental Leave
401(k) + match
Employee Stock Purchase Plan
Generous Paid Time Off – accrued based on years of service
WA Candidates: the accrual rate is 4.61 hours every other week for the first two years of tenure before increasing with additional years of service
10 paid company holidays
Tuition reimbursement
Flexible Spending Account
Employee Assistance Program
Sick time benefits – for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year, unless the laws of the state in which the employee is located provide for more generous sick time benefits