Outpatient Payment Integrity Coder

🕒 August 21

🇺🇸 United States – Remote

💵 $58k - $65k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥 Medical Billing and Coding

👻 Ghost score 18%

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MedReview Inc.

WebsiteLinkedInAll Job Openings

201 - 500 employees

🏥 Healthcare

⚕️ Healthcare Insurance

💸 Finance

Healthcare • 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.

📋 Description

• Perform outpatient coding reviews using medical records, itemized bills, claim lines, payer requirements, CPT/HCPCS guidance, ICD-10-CM guidelines, revenue codes, modifier rules, NCCI edits, APC/EAPG logic, and supporting documentation • Validate whether billed outpatient services are supported by documentation and whether the correct procedure codes, modifiers, units, revenue codes, and billing combinations were reported • Identify coding discrepancies, unsupported services, unbundling, inappropriate modifier usage, incorrect procedure code selection, unit errors, documentation deficiencies, and other outpatient payment integrity findings • Apply approved audit target guidance, job aids, payer policy, coding hierarchy, and documentation standards consistently across assigned claims • Document audit rationale clearly and defensibly, including supported findings, unsupported findings, code changes, modifier issues, documentation gaps, and references used to support the review decision • Meet production, quality, turnaround time, and general professional expectations while maintaining accuracy and consistency • Escalate complex coding, payer policy, reimbursement, pricing, workflow, or documentation questions to the appropriate lead, manager, or subject matter expert • Participate in training, calibration reviews, quality feedback sessions, and target refreshers • Maintain current knowledge of outpatient coding guidelines, payer policies, CMS guidance, NCCI edits, LCDs/NCDs, modifier requirements, and reimbursement methodologies • Complete assigned claims in accordance with approved workflow, target guidance, quality standards, and turnaround time expectations • Maintain accurate notes, apply coding guidance consistently, participate in quality review and calibration activities, and respond to feedback • Maintain confidentiality, exercise objective judgment, and support accurate payment outcomes through consistent application of approved coding and audit criteria

🎯 Requirements

• Current nonexpired coding certification credential required: CPC, COC, CCS, RHIT, RHIA or equivalent • Minimum of 3 years of outpatient coding experience required • Strong knowledge of CPT, HCPCS, ICD-10-CM, revenue codes, modifier usage, NCCI edits, outpatient documentation standards, and payer-specific coding requirements • Experience 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 • Ability to interpret payer policy, CMS guidance, LCDs/NCDs, coding references, and documentation requirements and apply them to claim-level reviews • Ability to distinguish between coding validation and payment integrity auditing • Strong written communication skills with the ability to document clear, concise, and defensible audit rationale • High attention to detail, analytical thinking, sound judgment, and ability to work independently in a production environment • Ability to meet productivity and quality expectations while managing multiple claims, priorities, and deadlines • Proficiency with Microsoft Outlook, Word, Excel, coding tools, claim review platforms, and electronic medical record documentation systems • Previous payment integrity, audit, outpatient facility audit, payer review, or claims review experience preferred • Experience with outpatient reimbursement methodologies such as 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 • Optum platforms experience

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