Outpatient Coding Product Manager

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November 13

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MedReview Inc.

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Healthcare Insurance • Finance

MedReview Inc. is a leading provider of advanced payment integrity solutions, specializing in healthcare claims. They work with a wide range of clients, including health plans, government agencies, and payors, to reduce unnecessary waste and save billions of dollars. Their team of highly trained physicians, registered nurses, and certified coders conduct thorough clinical and coding reviews to identify inaccuracies in healthcare claims. MedReview employs proprietary algorithms to analyze complex data and detect suspicious payment trends, offering a unique blend of clinical expertise and advanced technology to maximize efficiencies and improve healthcare cost management.

201 - 500 employees

⚕️ Healthcare Insurance

💸 Finance

📋 Description

• Provide subject matter expertise in outpatient hospital and professional reimbursement methodologies, especially including APC, EAPG, and other grouper-based methodologies. • Review and interpret client guidelines and policy, provider contract language, and State and Federal regulations to identify audit opportunities. • Develop, refine, and validate audit concepts and payment integrity rules to identify inappropriate billing and resulting payment errors. • Collaborate with product, data analytics and technology teams to design and test outpatient claim selection logic. • Analyze large volumes of claims data to identify coding trends, billing patterns, and emerging opportunities for new audits. • Interpret and apply CMS and payer guidelines to ensure regulatory compliance and alignment with current coding standards. • Support product development initiatives by providing clinical and coding insight throughout the product lifecycle. • Assist with documentation, training materials, and validation testing for new and updated audit concepts. • Champion training for auditors and coders to ensure consistent application of outpatient audit methodologies. • Review audit findings for selection accuracy and to ensure alignment with regulatory and payer policies. • Provide input on operational workflows and documentation standards to improve audit efficiency and quality. • Monitor and communicate regulatory updates affecting outpatient reimbursement. • Prepare and present findings, reports and recommendations to internal stakeholders.

🎯 Requirements

• Coding Certification is required. • RHIT, Certified Outpatient Coder (COC), or similar certification preferred. • Certified Professional Coder (CPC) or Apprentice Certified Outpatient Coder (COC-A) accepted. • Strong analytical and data comprehension skills are required. • SQL or Python coding experience is desirable. • Additional clinical background is preferred but not required. • At least 5 years of experience in hospital outpatient coding required. • Surgical coding is particularly desirable. • Extensive expertise with various outpatient reimbursement methodologies. • Knowledge of all payer types including Medicare, Medicaid, and Commercial plans. • Prior experience in payment integrity and audit development strongly preferred. • Familiarity with data analytics and audit selection processes.

🏖️ Benefits

• Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents. • 401(k) with Employer Match - Join the team and we will invest in your future • Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, to observe holidays. • Wellness - We care about your well-being. From Commuter Benefits to FSAs, we’ve got you covered. • Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional.