APC Coding Validation Specialist

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $85k - $100k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥 Medical Billing and Coding

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Machinify

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

🤖 Artificial Intelligence

☁️ SaaS

💰 $10M Series A - Machinify on 2018-10

Healthcare Insurance • Artificial Intelligence • SaaS

Machinify is a healthcare-focused AI platform and services company that reshapes healthcare payments and payment integrity. Its AI operating system unifies claims, medical records, contracts, and policies, and uses foundation models and task-specific agents to automate and improve coding, payment accuracy, recoveries, and cost avoidance. Machinify serves health plans (including 18 of the top 20), supports insourced, hybrid, or fully-managed deployments, and emphasizes measurable outcomes — reporting 85+ customers, 270M member lives covered, and $6B+ in annual cost avoidance and recoveries.

📋 Description

• Conduct comprehensive reviews to validate the accuracy of billed charges against medical documentation, payer policies, coding guidelines, and industry standards to ensure appropriate reimbursement. • Apply coding guidelines across a broad range of outpatient services, including but not limited to Interventional Radiology, Radiation Oncology, injections and infusions, outpatient surgeries, implants, and observation services (including carve-outs). • Demonstrate a strong working knowledge of outpatient reimbursement methodologies, including Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classification (APC), and Enhanced Ambulatory Patient Grouping (EAPG). • Apply expert-level knowledge of NCCI edits, including appropriate modifier usage, as well as CPT and HCPCS coding guidelines. • Interpret and apply Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs). • Produce clear, concise, and defensible audit findings that accurately articulate reimbursement impact. • Develop and apply well-supported rationales for coding changes impacting reimbursement, referencing appropriate sources such as AMA Official Coding Guidelines, CPT Assistant, AHA Coding Clinic, payer policies, and other industry-standard resources. • Work effectively both independently and collaboratively within a production-driven environment. • Maintain established accuracy, quality, and productivity standards, including correct code assignment and thorough documentation of review outcomes. • Utilize computer applications and tools, including Grouper/Pricer software, ICD-10-CM encoders, and Microsoft Office products. • Adhere to the Standards of Ethical Coding as established by AHIMA. • Perform additional duties as assigned.

🎯 Requirements

• Associate’s or Bachelor’s degree in Health Information Management, Medical Coding, or a related field • At least 2 years of experience performing pre-pay and/or post-pay reimbursement audits • Broad outpatient facility auditing experience, including specialty areas such as Interventional Radiology, injections and infusions, Radiation Oncology, Behavioral Health, and ambulatory surgery • Active certification including RHIT, RHIA, CCS (AHIMA), and/or CPC • 5-7 years of experience in outpatient facility coding/auditing • Sound knowledge of ICD-10-PCS/CM, CPT, and HCPCs coding guidelines • Experience performing pre- and post-payment reimbursement audits • Expertise in Medicare regulations, including LCDs, NCDs, NCCI edits, OPPS, and APC methodologies • Demonstrated experience with APC payment methodologies, OPPS reimbursement logic, fee schedules, and payer contracts • Excellent verbal and written communication skills • Strong attention to detail and analytical skills • Experience with encoder and auditing tools (e.g., 3M, TrueBridge, Grouper/Pricer Software)

🏖️ Benefits

• Work from anywhere in the US! Machinify is digital-first. • Top Medical/Dental/Vision offerings • FSA/HSA • Tuition reimbursement • Competitive salary, 401(k) with company match • Additional health and wellness benefits and perks • Flexible and trusting environment where you’ll feel empowered to do your best work