[Hiring] Certified Medical Coder @Commence

Role Description

The Certified Coder performs coding-focused medical review of Medicare Part A/B and DMEPOS claims for the program. Certified coders apply Medicare policies and guidelines, ensuring claims are evaluated according to National and Local Coverage Determinations and CMS rules, and document clear, accurate findings for each claim. They compare paid claim information against the provider's clinical documentation – verifying the assigned ICD-10-CM, CPT, and HCPCS codes to confirm coding accuracy, ensure medical necessity, detect overpayments or underpayments, and confirm compliance with Medicare policy.

Qualifications

• 3+ years of direct experience in medical coding, medical billing, and/or coding quality assurance/auditing in a healthcare environment, including ICD-10-CM/PCS, CPT/HCPCS, and DRG/APR-DRG coding systems
• Active coding certification through AAPC or AHIMA: CPC, CCS, CCS-P, CRC, RHIA, or RHIT
• Ability to research, apply, and document coding determinations in accordance with CMS coverage, coding, and payment rules, including National and Local Coverage Determinations (NCDs/LCDs)
• Ability to work independently and productively in a remote, technology-driven, queue-based claims review environment
• Working knowledge of, and ability to comply with, HIPAA and other laws/regulations governing confidentiality and privacy of protected health information (PHI) and personally identifiable information (PII)
• Working knowledge of, and ability to comply with, CMS system and information security requirements
• Associate's degree in a related discipline, or an equivalent combination of certification and relevant experience in lieu of a degree

Requirements

• 3+ years of Medicare Fee-for-Service (FFS) claim review experience
• Experience with queue-based or low-code/no-code case management systems as an end user
• Prior experience on a CMS program integrity, audit, or medical review contract (e.g., MAC, RAC, UPIC, SMRC)

Key Responsibilities

• Perform coding-only medical reviews (no clinical judgment required) on Medicare Part A/B and DMEPOS claims, applying ICD-10-CM/PCS, CPT/HCPCS, and DRG/APR-DRG coding rules
• Research and apply NCDs, LCDs, and CMS coding/payment guidance to render and document coding determinations
• Identify potential improper payments, coding errors, and documentation patterns indicative of fraud, waste, or abuse for referral consideration
• Maintain claim review documentation in the designated case tracking system
• Support claim(s) re-review and provider education sessions as requested
• Maintain individual accuracy score in accordance with company standards
• Complete required annual trainings (e.g., ethics, records management, security controls) and maintain HIPAA/PHI compliance

Work Environment/Physical Demands

The work environment and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This is a remote position. While performing the duties of this job, the employee regularly works in a climate-controlled environment. Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods of time. Occasionally required to stand, walk, use hands and fingers, kneel or crouch.

Equal Employment Opportunity

Commence is an equal employment opportunity employer. All personnel processes are merit-based and applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military and veteran status or any other characteristic protected by applicable law.

Commence.AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or [email protected]. Please note that unless you are requesting an accommodation, all applications must be submitted through our online application system.