Overview
The Certified Medical Coder supports strategic growth initiatives by conducting comprehensive coding audits, data validation, and financial risk analysis during mergers, acquisitions, and divestitures. This position ensures the integrity of clinical coding, risk adjustment data, and claims accuracy to inform valuation, identify compliance risks, and quantify revenue impacts.
Essential functions:
Coding and Validation
- Review medical claims, encounter data, and/or clinical records to ensure accurate coding of ICD-10-CM diagnoses and CPT/HCPCS procedures and services
- Validate provider-submitted codes against documentation and payer policies
- Identify and correct coding discrepancies, errors, or unsupported services
- Apply payer-specific edits, policies, and coding guidelines
- Conduct coding audits to assess accuracy of:
- ICD-10-CM diagnoses
- CPT/HCPCS procedures
- Risk adjustment (HCC) coding
- Evaluate the organizations:
- Coding practices and controls
- Documentation sufficiency
- Audit history and compliance posture
- Identify exposure areas such as:
- Overcoding / upcoding risk
- Undercoding leading to revenue leakage
- Unsupported diagnoses (RADV risk)
Competencies:
- Strong attention to detail and accuracy
- Strong communication and stakeholder engagement skills
- Strong analytical and critical-thinking abilities
- Excellent written and verbal communication skills
- Strong organizational skills and ability to manage multiple priorities
- Ability to interpret clinical documentation
- Knowledge of regulatory and compliance requirements
- Effective written and verbal communication
- Proficient in Microsoft office suite
Required education and experience:
- Certified coding credential:
- CPC, CCS, or CCS-P required
- 5+ years of experience in:
- Health plan / payer coding
- Payment integrity
- Coding audit or chart review
- Strong knowledge of:
- ICD-10-CM, CPT, HCPCS
- CMS risk adjustment (HCC models)
- Commercial, Medicaid, Medicare and Medicare Advantage plans
- Demonstrated use and proficiency with EMR platforms and Microsoft Office applications
Physical Requirements/Work environment:
- Remote with periodic travel as required <5%
- Must have a home office, mobile phone, and computer with security requirements met
- Prolonged periods of sitting at a desk and working on a computer
- Ability to speak, hear, and comprehend both written and verbal communications
- Internet Speed Minimum of 100 Mbps download and 10–20 Mbps upload
- Typing/data entry of 40-55 WPM
Other duties:
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without advanced notice.
Pay: From $50.00 per hour
Experience:
- Health plan / payer coding: 5 years (Required)
- Coding audit or chart review: 5 years (Required)
- payment integrity: 5 years (Required)
License/Certification:
- certified coding credential (Required)
Work Location: Remote
