Certified Medical Coder

Responsibilities 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. Coordinates research and responds to system inquiries and appeals. Conducts research of claims systems 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. Mandatory experience in payor insurance processes THE CANDIDATES MUST HAVE WORKED MORE WITHIN THE INSURANCE INDUSTRY AND LESS ON THE PROVIDER SIDE ( HOSPITAL, DOCTORS ETC). Qualifications Certified & active Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent certification required. Experience with appeals and denials (NCD/LCD, Duplicate, MUE) 2-3 years of prior E&M/GMC experience Strong knowledge of CPT, HCPCS, ICD-10, and CMS reimbursement guidelines. Minimum 3 years experience reviewing denied claims and performing coding audits in a healthcare or insurance environment. Excellent analytical, communication, and documentation skills with an emphasis on attention to detail. Ability to interpret medical records and apply coding principles accurately. #J-18808-Ljbffr