About this role
Skills Required
• Strong analytical and critical-thinking skills • Excellent medical record review and interpretation skills • Effective written and verbal communication • Ability to work independently and manage multiple priorities • Knowledge of denial management and appeals processes • Strong problem-solving and research capabilities
Performance Metrics
• Quality Accuracy ≥ 98% • Achievement of Productivity Targets • SLA/TAT Adherence • Compliance with Process and Documentation Standards • Minimal Audit Defects and Rework
• Review and resolve Code Edit, Provider Payment Integrity (PPI), PCI, and Appeals work queues. • Analyze medical records, provider documentation, claim history, and coding guidelines. • Validate CPT, HCPCS, ICD-10-CM, modifiers, and reimbursement methodologies. • Apply CMS, NCCI, Medicare, Medicaid, and commercial payer editing guidelines. • Research coding disputes and provide supporting rationale for determinations. • Maintain productivity, quality, and turnaround time targets. • Escalate complex coding scenarios and policy interpretation issues appropriately. • Update productivity, clarification, and audit logs daily. • Participate in internal and external quality audits. • Identify trends and recommend process improvements. • Ensure compliance with HIPAA, OIG, and organizational policies. • Respond promptly to client and leadership communications.
Qualifications & Experience
• Life Science / Paramedical / Healthcare-related degree • Active CPC, CCS certification • Strong knowledge of CPT, HCPCS, ICD-10-CM, NCCI edits, CMS guidelines, and payer policies • Proficiency in MS Office and healthcare applications • Willing to work in Eastern (US) shift when required Experience
• Minimum 2+ years of medical coding experience • Experience in Surgery, E&M, or Denial Management is mandatory. • Experience in code edit review, appeals, grievances, provider disputes, or payment integrity programs is an advantage Working Hours
• Full-time (40 hours per week) • Shift timing based on business requirements • Weekends Off (subject to project need)