Outpatient Coding Validation Specialist

The company is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, the company brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

About the Opportunity

As a Coding Validation Specialist on the Complex Payment Solutions Team, you will play a critical role in performing comprehensive outpatient payment validation reviews. Leveraging your expertise in coding guidelines, outpatient reimbursement methodologies, and regulatory requirements, you will ensure accurate and compliant payment determinations.

In this role, you will review medical records to validate the accuracy of coding, billing, and supporting documentation for outpatient services, including APCs, EAPGs, CPT, and HCPCS Level II codes. You will clearly document audit findings and provide well-supported rationales, citing applicable payer policies, coding guidelines, and industry-standard references.

This position requires exceptional attention to detail, expert-level proficiency in ICD-10-CM/PCS, CPT, and HCPCS coding guidelines, and a strong understanding of outpatient reimbursement methodologies.

What you’ll do

• Conduct comprehensive reviews to validate the accuracy of billed charges against medical documentation, payer policies, coding guidelines, and industry standards to ensure appropriate reimbursement.

• Apply coding guidelines across a broad range of outpatient services, including but not limited to Interventional Radiology, Radiation Oncology, injections and infusions, outpatient surgeries, implants, and observation services (including carve-outs).

• Demonstrate a strong working knowledge of outpatient reimbursement methodologies, including Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classification (APC), and Enhanced Ambulatory Patient Grouping (EAPG).

• Apply expert-level knowledge of NCCI edits, including appropriate modifier usage, as well as CPT and HCPCS coding guidelines.

• Interpret and apply Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).

• Produce clear, concise, and defensible audit findings that accurately articulate reimbursement impact.

• Develop and apply well-supported rationales for coding changes impacting reimbursement, referencing appropriate sources such as AMA Official Coding Guidelines, CPT Assistant, AHA Coding Clinic, payer policies, and other industry-standard resources.

• Work effectively both independently and collaboratively within a production-driven environment.

• Maintain established accuracy, quality, and productivity standards, including correct code assignment and thorough documentation of review outcomes.

• Utilize computer applications and tools, including Grouper/Pricer software, ICD-10-CM encoders, and Microsoft Office products.

• Adhere to the Standards of Ethical Coding as established by AHIMA.

• Perform additional duties as assigned.

What experience you bring (Role Requirements)

• 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 such as Interventional Radiology, injections and infusions, Radiation Oncology, Behavioral Health, and ambulatory surgery

• 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)

Pay range: $85,000 - $100,000, with the opportunity to earn quarterly bonuses. The salary for this position is based on an array of factors unique to each candidate: Such as years and depth of experience, set skills, certifications, etc.  We are hiring for different levels, and our Recruiting team will let you know if you qualify for a different role/range.

What We Offer

• Work from anywhere in the US! The company is digital-first.

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Top Medical/Dental/Vision offerings

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FSA/HSA

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Tuition reimbursement

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Competitive salary, 401(k) with company match

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Additional health and wellness benefits and perks

• Flexible and trusting environment where you’ll feel empowered to do your best work

Equal Employment Opportunity at the company

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. The company is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at:  [link for members]