Senior Medical Coding Specialist (Remote

Position Overview

The Senior Medical Coding Specialist acts as an internal expert to ensure that value‑based reimbursement and medical policy models are developed and implemented to support Payment Integrity. This role provides expert knowledge to support effective partnership with provider entities, guidance on the appropriate quality‑measure capture and proper use of CPT and ICD‑10 codes in claims submissions. The specialist utilizes coding expertise, combined with medical policy, credentialing and contracting rules knowledge, to build effective guidelines and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity.

This role also provides expertise and mentoring to other team members and will sit within the Payment Integrity team.

• Consult on proper coding rules in value‑based contracts to ensure appropriate quality‑measure capture and proper use of CPT and ICD‑10 codes. Provide insight on consequences for different financial and incentive models. Strategize alternatives and solutions to maximize quality payments and risk adjustment. Translate from claim language to services in an episode or capitated payment to articulate inclusions and exclusions in models.
• Serve as a technical resource and coding subject‑matter expert for contract‑pricing related issues. Conduct complex business and operational analyses to assure payments are compliant with contract, identify areas for improvement and clarification for better operational efficiency. Provide problem‑solving expertise on system issues if a code is not accepted. Troubleshoot, make recommendations and answer questions on more complex coding and billing issues.
• Develop and refine effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity. May interface directly with provider groups during proactive training events or on‑the‑fly complex claims matters. Consult with various teams, including the Practice Transformation Consultants, Medical Policy Analysts and Provider Networks colleagues to interpret coding and documentation language and respond to inquiries from providers.
• Participate in strategy and contribute to thought leadership for quality‑measure capture (NCQA, HEDIS, STARs). Collaborate with internal stakeholders on process and outcome improvement activities. Ensure compliance with all coding standards.
• Facilitate mentorship, providing assistance to less seasoned team members.
• Actively research industry trends, keeping up‑to‑date and maintaining a high level of expertise in coding rules and standards.

Position has no direct reports but is expected to assist in guiding and mentoring less experienced staff and may lead a team of matrixed resources.

Bachelor's Degree or, in lieu of a Bachelor's, an additional 4 years of relevant work experience is required in addition to the required work experience.

• CCS‑Certified Coding Specialist
• Certified Coder (CCS or CPC) – AHIMA or AAPC

Five years’ experience in risk‑adjustment coding, ambulatory coding and/or CRC coding experience in managed care; state or federal health‑care programs; or health insurance industry experience.

• Certified public accountant
• Experience in medical auditing
• Experience in training, education or presenting to large groups

• Knowledge of billing practices for hospitals, physicians and/or ancillary providers as well as knowledge about contracting and claims processing.
• Experience in revenue‑cycle management and value‑based reimbursement/contracting models and methodologies.
• Detail‑oriented with the ability to manage multiple projects simultaneously.
• Excellent written and verbal communication skills.
• Demonstrated ability to analyze and present data effectively.
• Ability to create educational materials, training manuals and procedural guides.
• Experience in using Microsoft Office (Excel, Word,…