[Hiring] Medical Coding Specialist @Claritev

Role Description

The Medical Coding Specialist is responsible for providing billing analysis of claims and applying coding standards and federal regulations to ensure correct billing practices. In this role, you will perform bill and chart reviews to identify any variation from quality billing practices and monitor patient bills for accuracy and compliance. This position also requires awareness of international coding systems and healthcare billing practices to support global operations and ensure alignment with international regulatory standards.

Duties

• Review and analyze inpatient, outpatient, and provider billing for medical appropriateness of treatment.
• Analyze charges across various revenue centers with consideration to patient diagnosis, procedures, age, facility type, and international healthcare norms where applicable.
• Apply recommendation of national coding and international coding and regulation standards (e.g., ICD-10-AM, OPCS-4, SNOMED CT) to claims billed.
• Prepare clear, concise and legible findings, including documentation that may be used in cross-border audits or international compliance reviews.
• Research, review and provide internal response based on receipt of itemized bills, claims, operative notes and other documentation, including those from international providers or translated medical records.
• Assist with, create or enhance internal claim and review recommendations.
• Communicate with co-workers and management regarding clinical and reimbursement findings.
• Assist with clinical education of staff as it relates to clinical aspects of claims, suggesting additional negotiation talking points or tools, and communicating overall industry or regulatory changes which affect the department.
• Monitor, research, and summarize trends, coding practices, and regulatory changes across multiple countries or regions.
• Research and review individual claims, claim trends or detailed itemized bills, operative notes and other documentation as needed.
• Collaborate, coordinate, and communicate across disciplines and departments.
• Ensure compliance with HIPAA and international data protection regulations (e.g., GDPR, PIPEDA).
• Demonstrate commitment to the Company's core values.

Requirements

• Minimum completion of educational curriculum required of medical license or coding certification held with Bachelor's Degree preferred; or minimum Bachelor's Degree in healthcare related field and at least 2 years of coding experience.
• Current nursing certification and/or current certified coder (CCS, CCS-P or CPC), Registered Health Information Technician (RHIA/RHIT).
• Minimum 2 years experience in direct patient care, medical procedure billing, medical insurance auditing, line item review, audits, coding, and/or reimbursement.
• Knowledge of inpatient/outpatient hospital billing requirements including UB-04s, revenue codes, CPT, HCPCS, ICD-9/10, DRG, APCs, and familiarity with international equivalents (e.g., KSA, ICD-10-AM, ACHI, CCI).
• Knowledge of professional claim billing requirements including HCFA-1500s, CPT codes and ICD-9/ICD-10 diagnoses codes, as well as international claim forms.
• Knowledge of payer reimbursement policies, state and federal regulations, international healthcare systems, and global medical necessity criteria.
• Familiarity with international medical data resources and coding tools.
• Auditing and health information management experience in a healthcare setting preferred.
• Excellent communication (verbal and written), teamwork, training, presentation, negotiation and organizational skills, including cross-cultural communication.
• Proficiency in MS Office Suite and database software; experience with international billing platforms is a plus.
• Ability to handle multiple tasks in a fast paced environment.
• Ability to read and abstract medical records.
• Knowledge of medical terminology, anatomy, and physiology.
• Ability to interact and discuss audit results with providers.
• Required licensures, professional certifications, and/or Board certifications as applicable.
• Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone.

Benefits

• Medical, dental and vision coverage with low deductible & copay.
• Life insurance.
• Short and long-term disability.
• Paid Parental Leave.
• 401(k) + match.
• Employee Stock Purchase Plan.
• Generous Paid Time Off – accrued based on years of service.
• 10 paid company holidays.
• Tuition reimbursement.
• Flexible Spending Account.
• Employee Assistance Program.
• Sick time benefits – for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year.