Certified Medical Coder

Responsibilities

• Review adjudicated medical claims that have been denied and resubmitted by providers for reconsideration.
• Review medical documentation in support of Evaluation and Management in compliance with current CPT, HCPCS, ICD-10, and CMS guidelines, as well as company-specific reimbursement policies, competitor specific medical policies, reimbursement policies, and editing rules, as well as conducting clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.
• Analyze claim documentation, coding accuracy, and medical record details to determine if denial reasons are valid or if payment reconsideration is warranted.
• Conduct detailed coding audits to validate proper code assignment and adherence to medical necessity and billing regulations.
• Coordinates research and responds to system inquiries and appeals.
• Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.
• Prepare clear and concise documentation outlining findings, coding corrections, and recommendations for claim outcomes.
• Mandatory experience in payor insurance processes

THE CANDIDATES MUST HAVE WORKED MORE WITHIN THE INSURANCE INDUSTRY AND LESS ON THE PROVIDER SIDE ( HOSPITAL, DOCTORS ETC).

• Certified & active Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent certification required.
• Experience with appeals and denials (NCD/LCD, Duplicate, MUE)
• 2-3 years of prior E&M/GMC experience
• Strong knowledge of CPT, HCPCS, ICD-10, and CMS reimbursement guidelines.
• Minimum 3 years experience reviewing denied claims and performing coding audits in a healthcare or insurance environment.
• Excellent analytical, communication, and documentation skills with an emphasis on attention to detail.
• Ability to interpret medical records and apply coding principles accurately.