Medical Coders - QA​/SME Specialist

Overview

Quality Analyst/ SME for GMC & E&M services for medical coding who will be responsible for conducting quality reviews, ensuring compliance with CMS and payer-specific guidelines, and driving accuracy within health Insurance coding operations. The Quality Analyst will serve as a key resource for coding audits, error analysis, coder feedback and supporting revenue integrity initiatives. This leadership position will assist in supervising and leading a team of medical coders specializing in GMC & E&M services.

• Review adjudicated medical claims that have been denied and resubmitted by providers for reconsideration.
• Review medical documentation in support of Evaluation and Management in compliance with current CPT, HCPCS, ICD-10, and CMS guidelines, as well as company-specific reimbursement policies, competitor specific medical policies, reimbursement policies, and editing rules, as well as conducting clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.
• Analyze claim documentation, coding accuracy, and medical record details to determine if denial reasons are valid or if payment reconsideration is warranted.
• Conduct detailed coding audits to validate proper code assignment and adherence to medical necessity and billing regulations.
• Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.
• Conducts research of claims systems (i.e Facets, Encoder Pro, etc) and system edits to identify adjudication issues and to audit claims adjudication for accuracy.
• Prepare clear and concise documentation outlining findings, coding corrections, and recommendations for claim outcomes.
• Create and maintain Quality assurance program.
• Mandatory experience in payor insurance processes (Must).
• Supervise and lead a team of medical coders specializing in GMC & E&M services. Minimum 15 team members.
• Assign, monitor, and review coding work to ensure accuracy, timeliness, and compliance with CMS and payer-specific requirements.
• Conduct regular quality audits and provide feedback to coders to maintain error rates within acceptable thresholds.
• Serve as the SME for GMC & E&M coding guidelines, 1995/1997 and 2021 AMA/CMS updates, and documentation requirements.
• Collaborate with providers, auditors, and compliance teams to address queries and resolve coding discrepancies.
• Develop and deliver training programs for new and existing coders on GMC & E&M coding and documentation changes.
• Track team productivity, create performance reports, manage coding performance and perform in depth analysis on performance as needed.
• Support medical necessity and revenue integrity initiatives through accurate GMC & E&M code assignment.

• Live within the Tampa Bay or Atlanta Metro area. May be required to come into the local office on occasion.
• REQUIRED Certified & active serving Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent certification required
• Experience with appeals and denials (NCD/LCD, Duplicate, MUE)
• REQUIRED - minimum of 5 years of prior E&M/GMC experience
• Minimum of 5 years of experience in a leadership capacity
• Strong knowledge of CPT, HCPCS, ICD-10, and CMS reimbursement guidelines.
• REQUIRED - Minimum 3 years experience reviewing denied claims and performing coding audits in a healthcare or insurance environment
• Experience handling multiple internal and external stakeholders.
• Excellent analytical, communication, and documentation skills with an emphasis on attention to detail.
• Ability to interpret medical records and apply coding principles accurately.
• Prior experience leading a coding team or acting as a Quality Reviewer/SME in GMC & E&M coding.
• Ability to work independently and as part of a team in a fast-paced environment.

Mandatory

Skills:

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Experience: 3-5 Years.

The expected compensation for this role ranges from $80,000 to $85,000.

Final compensation will depend on various factors, including your geographical location, minimum wage obligations, skills, and relevant experience. Based on the position, the role is also…