Medical Coding & Reimbursement Specialist

What You Will Do

We are seeking a Senior Medical Coding & Reimbursement Specialist to support federal health programs by providing expertise in healthcare coding, reimbursement, provider billing practices, and claims operations. In this role, you will help shape how coding standards, reimbursement requirements, provider billing workflows, and healthcare service relationships are analyzed, evaluated, and operationalized across clinical, operational, reimbursement, and analytics stakeholders.

Strategy & Transformation Consulting

Up to 25%

Ability to Obtain Public Trust

We are seeking a Senior Medical Coding & Reimbursement Specialist to support federal health programs by providing expertise in healthcare coding, reimbursement, provider billing practices, and claims operations. In this role, you will help shape how coding standards, reimbursement requirements, provider billing workflows, and healthcare service relationships are analyzed, evaluated, and operationalized across clinical, operational, reimbursement, and analytics stakeholders.

You will apply knowledge of CPT, HCPCS, ICD-10, modifiers, revenue codes, claims adjudication, and reimbursement methodologies to support consistent decision-making, improve operational understanding, and ensure healthcare services are accurately represented within program processes and supporting frameworks. The ideal candidate brings deep coding and reimbursement expertise combined with an understanding of how healthcare services move from clinical delivery through documentation, coding, billing, adjudication, and payment.

Responsibilities will include:

• Develop, refine, and maintain CPT, HCPCS, ICD-10, modifier, revenue code, and ancillary service code groupings.
• Support development of code sets that accurately represent episodes of care, treatment pathways, and healthcare services.
• Research coding guidance, Medicare policies, reimbursement methodologies, and billing requirements to support code inclusion and exclusion decisions.
• Identify related, supporting, bundled, ancillary, add-on, and downstream services associated with diagnoses and procedures.
• Validate code sets against Medicare requirements, fee schedules, reimbursement policies, NCCI edits, and coding standards.
• Review provider billing practices and claims patterns to identify missing, duplicative, or inappropriate code relationships.
• Document coding rationale, business rules, assumptions, exclusions, and validation findings.
• Participate in coding reviews, clinical reviews, quality control activities, and stakeholder reviews.
• Collaborate with clinicians, reimbursement SMEs, and analytics teams to evaluate code inclusion, exclusion, and grouping decisions.
• Support governance processes, change requests, maintenance activities, and version control efforts.

• 2+ years of experience in medical coding, reimbursement, payment integrity, auditing, compliance, revenue cycle, or claims operations.
• Strong knowledge of CPT, HCPCS, ICD-10-CM, ICD-10-PCS, revenue codes, modifiers, Medicare reimbursement methodologies, claims adjudication, provider billing workflows, NCCI edits, and fee schedules.
• Experience working within payer, provider, TPA, Medicare, Medicaid, TRICARE, Commercial, or Federal healthcare environments.
• Ability to translate coding guidance and reimbursement requirements into operationally actionable code set recommendations.
• Candidates should possess one or more of the following certifications:
• Certified Professional Coder (CPC)
• Certified Outpatient Coder (COC)
• Certified Professional Medical Auditor (CPMA)
• Certified Risk Adjustment Coder (CRC)
• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified in Healthcare Compliance (CHC)
• Certified Emergency Department Coding Specialist (CEDC)
• Certified OBGYN Coding Specialist (COBGC)
• Certified Orthopedic Surgical Coding Specialist (COSC)

• Experience supporting federal health programs, Medicare-based payment models, or large payer environments.
• Exposure to authorization, utilization management, payment integrity, or claims analytics initiatives where coding decisions affect operational or financial outcomes.
• Experience working with analytics or technical teams to translate coding and reimbursement logic into business rules, validation criteria, or operational requirements.
• Familiarity with specialty-specific coding areas such as emergency medicine, orthopedics, behavioral health, women’s health, durable medical equipment, or surgical/procedural services.
• Preference will be given to candidates local to the Washington, DC metro area.

The annual salary range for this position is $98,000.00-$. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs.

Guidehouse offers a…