Revenue Integrity Coding Billing Specialist

Under the direction of the Director of Revenue Integrity, the Revenue Integrity Coding Billing Specialist provides revenue cycle support services through efficient review and timely resolution of assigned Medicare and third party payer accounts that are subject to pre-bill claim edits, hospital billing scrubber bill hold edits, and claim denials. This position is 100% remote.

Daily duties for this position include:

• Responsible for the daily resolution of assigned claims with applicable Revenue Integrity pre-bill edits and/or specific Revenue Integrity Hold Codes in the hospital billing scrubber. Tasks associated with this work include resolving standard billing edits such as:

• Correct Coding Initiatives (CCI)

• Medically Unlikely Edits (MUE)

• Medical Necessity edits

• Other claim level edits as assigned

• As needed, review clinical documentation and diagnostic results as appropriate to validate and apply applicable ICD-10, CPT, HCPCS codes and associated coding modifiers.

• Responsible for daily resolution of assigned claims with Revenue Integrity specific denials in the Guidehouse METRIX℠ system.

• Ensures coding and billing practices are in compliance with Federal/State guidelines by utilizing various types of authoritative information.

• Maintains current knowledge of Medicare, Medicaid, and other third-party payer billing compliance guidelines and requirements.

• Other duties commensurate with skills and experience as determined by the Director of Revenue Integrity.

What You Will Need: 

• High School Diploma or equivalent

• 5+ years of Revenue Integrity experience

• AAPC or AHIMA coding certification. 

• Experience in ICD-10, CPT and HCPCS Level II Coding.

• Expertise in determining medical necessity of services provided and charged based on provider/clinical documentation.

• Knowledge, understanding and proper application of Medicare, Medicaid, and third-party payer UB-04 billing and reporting requirements including resolution of CCI, MUE and Medical Necessity edits applied to claims.

• Proficiency in determining accurate medical codes for diagnoses, procedures and services performed in the outpatient setting. For example: emergency department visits, outpatient clinic visits, same day surgeries, diagnostic testing (radiology, imaging, and laboratory), and outpatient therapies (physical therapy, occupational therapy, speech therapy, and chemotherapy)

• Knowledge of current code bundling rules and regulations along with proficiency on issues regarding compliance, and reimbursement under outpatient grouping systems such as Medicare OPPS and Medicaid or Commercial Insurance EAPG’s.

• Knowledge and understanding of hospital charge description master coding systems and structures.

• Strong verbal, written and interpersonal communication skills.

• Ability to produce accurate, assigned work product within specified time frames.

What Would Be Nice To Have:

• 5 years' experience in Revenue Integrity Coding and Billing

• Hospital medical billing and auditing experience

• Associate's degree

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