Outpatient Coding Validation Specialist

The role

You will perform outpatient payment validation reviews by reviewing medical records to validate coding, billing, and documentation accuracy. You will apply coding guidelines and reimbursement methodologies to ensure compliant payment determinations.

What you will do

• Conduct comprehensive reviews to validate billed charges against medical documentation and payer policies
• Apply coding guidelines across outpatient services including Interventional Radiology, Radiation Oncology, and outpatient surgeries
• Demonstrate knowledge of Medicare Outpatient Prospective Payment System, APC, and EAPG
• Apply expert-level knowledge of NCCI edits, CPT, and HCPCS coding guidelines
• Interpret and apply Medicare Local Coverage Determinations and National Coverage Determinations
• Produce clear and defensible audit findings regarding reimbursement impact
• Develop well-supported rationales for coding changes using industry-standard resources
• Work independently and collaboratively within a production-driven environment
• Maintain accuracy, quality, and productivity standards
• Utilize computer applications including Grouper/Pricer software and ICD-10-CM encoders

Required qualifications

• 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
• 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

• Top Medical/Dental/Vision offerings
• FSA/HSA
• Tuition reimbursement
• Competitive salary
• 401(k) with company match
• Additional health and wellness benefits and perks

About the company

Machinify is a healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. It uses an AI-powered platform to maximize financial outcomes and drive down healthcare costs.