Claim Review Specialist - Facility Coding - Certification Required

Job description

**This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Claim Review Specialist - Facility Coding - Certification Required based in the United States.** This fully remote role supports healthcare revenue cycle performance through detailed outpatient facility claim reviews and coding analysis. You’ll assess claims, medical documentation, charges, coding accuracy, and reimbursement requirements to identify opportunities for improvement. The position combines technical coding expertise with analytical problem-solving and client-facing communication. You’ll work closely with HIM and revenue cycle leadership while contributing to audits, reporting, education, and documentation improvement initiatives. The role offers exposure to diverse outpatient settings, payer requirements, and evolving CMS coding and reimbursement guidelines. It is well suited to an experienced coding professional who enjoys independent work, technology-enabled auditing, and making measurable improvements to financial and operational outcomes. ### Accountabilities - Review outpatient hospital and professional-fee claims using proprietary software, data trends, and supporting medical documentation. - Conduct comprehensive claim audits covering omitted or incorrect charges, coding accuracy, documentation, units of service, and billing elements. - Apply OPPS, Critical Access Hospital, CMS, Medicare, Medicaid, Medi-Cal, payer-specific, NCCI, and MUE guidelines as applicable. - Evaluate ICD-10-CM, CPT, and HCPCS coding, including facility E/M, emergency department, same-day surgery, observation, ancillary, interventional radiology, and related services. - Identify coding, charge, billing, and documentation improvement opportunities and recommend appropriate changes. - Become proficient in the organization’s proprietary claim-review and data-analysis software and use it to develop standardized reports. - Research new coding guidelines, payer specifications, data elements, and reimbursement requirements to maintain current expertise. - Support client meetings and presentations, answer coding questions, and communicate findings clearly and professionally. - Prepare written Q&A and FAQ materials and contribute educational content for clients and internal revenue cycle teams. - Collaborate with HIM and revenue cycle consulting professionals while providing technical support and subject-matter expertise. - Maintain required certifications and continue developing knowledge across assigned specialty areas, including inpatient coding as needed. - Perform additional responsibilities aligned with business and client needs. ## Requirements - 5+ years of current, directly relevant experience in outpatient facility coding. - Current **CCS, COC, or CPC certification** through AHIMA or AAPC is required; CPC-A certification is not accepted. - Extensive expertise in outpatient facility coding, including emergency department, same-day surgery, observation, ancillary services, interventional radiology, facility E/M, and related areas. - Strong knowledge of revenue cycle processes, outpatient coding and billing, CMS guidelines, Medicare and Medicaid requirements, and payer-specific rules. - Working knowledge of ICD-10-CM, CPT, HCPCS, revenue codes, NCCI/CCI edits, MUEs, units of service, and OPPS reimbursement. - Strong understanding of medical terminology, anatomy, clinical documentation, and coding guidelines. - Inpatient facility coding and clinical documentation experience is preferred; willingness to develop inpatient expertise is expected. - Experience in a Critical Access Hospital environment is a plus. - Strong analytical, research, critical-thinking, and decision-making abilities, with the capacity to work independently. - Excellent written and verbal communication skills, including the ability to explain complex coding matters clearly and professionally. - Strong client-service, presentation, and relationship-building skills. - Proficiency with Microsoft Excel, PowerPoint, Word, and OneNote, along with strong overall technology and computer skills. - Ability to work effectively from a home office and remain organized while managing multiple priorities and deadlines. ## Benefits - Fully remote, work-from-home position within the United States. - Full-time, exempt employment. - Opportunity to work on healthcare revenue cycle, coding, reimbursement, and audit initiatives with meaningful client impact. - Professional development opportunities and continued exposure to evolving coding, reimbursement, and healthcare technology practices. - Opportunity to expand expertise into inpatient coding and broader revenue cycle consulting. - Collaborative environment combining clinical expertise, analytics, technology, and client engagement. - Competitive compensation and employee benefits are offered in accordance with the partner company’s applicable employment package and policies.