other
Posted Mar 13APC Coding Validation Specialist
at Machinify
United StatesRemote
Responsibilities
- Conduct comprehensive reviews to validate the accuracy of billed charges against medical documentation, payer policies, coding guidelines, and industry standards to ensure appropriate reimbursement.
- 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.
- 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.
- Perform additional duties as assigned. What
Requirements
- Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise.
- 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:
- 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.
- 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
- 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