Coding Subject Matter Expert

Job Description

Job Description

Description:

Healthrise is seeking a Coding Subject Matter Expert (SME) to serve as an escalation-level coding resource within one of three specialty focus areas: PB/ASC, Pathology/Radiology, or Primary Care (which may include ED Professional Fee and/or Hospital-Based Outpatient coding). This individual-contributor role handles complex and escalated coding work that falls outside the scope of the offshore coding team, applying deep specialty coding knowledge, critical thinking, and strong physician communication to keep claims accurate and compliant.

The SME works directly with physicians and providers to resolve documentation questions and coding queries within their assigned specialty area, ensuring accurate CPT, HCPCS, ICD-10, and modifier assignment. While the primary focus is professional billing (PB) coding, each SME maintains working knowledge of hospital-based (HB) coding to support broader coding needs as the department grows.

This is a strong opportunity for an experienced coder who wants to operate as a trusted specialty expert, partner closely with providers, and help shape coding standards as Healthrise builds out its front-end coding leadership structure.

Duties and Responsibilities

Core Responsibilities (All Specialty Areas)

• Knows, understands, incorporates, and demonstrates the Healthrise Core Values in all interactions with team members, clients, and stakeholders.

• Serve as the SME resource for the assigned specialty coding area, resolving complex or escalated cases that fall outside the offshore coding team’s scope.

• Serve as the primary point of contact for physician-facing coding queries within the assigned specialty, communicating directly with providers to clarify documentation and drive accurate code assignment.

• Apply critical thinking to identify documentation gaps and work collaboratively with providers to resolve them in a timely manner.

• Partner with Clinical Documentation Integrity (CDI), Compliance, and Revenue Integrity teams on documentation improvement opportunities specific to the assigned specialty.

• Provide coding guidance, QA feedback, and informal mentorship to offshore and junior coding staff within the assigned specialty.

• Support denial and audit response related to the assigned specialty coding area, including root-cause analysis.

• Stay current on CPT, HCPCS, and ICD-10 updates, NCCI edits, and payer policy changes affecting the assigned specialty.

• Maintain productivity and quality standards for escalated case review consistent with department expectations.

PB/ASC Specialty Focus

• Review and code ambulatory surgery center (ASC) and professional fee encounters across surgical specialties, ensuring accurate CPT, HCPCS, ICD-10, and modifier assignment.

• Apply knowledge of NCCI edits, medical necessity requirements, and payer-specific policies to resolve complex PB/ASC coding scenarios.

• Maintain working knowledge of hospital-based (HB) coding to support cross-coverage as departmental needs evolve.

Pathology/Radiology Specialty Focus

• Review pathology reports (surgical pathology, cytology, molecular) and radiology reports (diagnostic and interventional) to assign accurate CPT, ICD-10, HCPCS, and modifier codes, including professional (26) and technical (TC) component distinctions.

• Apply knowledge of NCCI edits, LCD/NCD policies, and payer-specific requirements relevant to pathology and radiology coding.

Primary Care / ED Profee / HB Outpatient Specialty Focus

• Review primary care encounters to ensure accurate Evaluation and Management (E/M) level assignment, CPT, ICD-10, and HCPCS coding in accordance with current E/M guidelines.

• Support Emergency Department (ED) professional fee and hospital-based (HB) outpatient coding as assigned, applying setting-specific coding and leveling requirements.

• Apply knowledge of NCCI edits, medical necessity requirements, and payer-specific policies across primary care, ED profee, and HB outpatient coding.

• Performs other duties as assigned.

Qualifications

Required - Core (All Specialty Areas)

• Active coding credential required, appropriate to the assigned specialty area (e.g., CPC, CCS, CCS-P, CASCC, CIRCC, CEMC, or equivalent AAPC/AHIMA credential).

• Minimum 5 years of coding experience within the assigned specialty area, with demonstrated subject matter expertise.

• Demonstrated experience communicating directly with physicians to resolve documentation and coding questions.

• Strong critical thinking, problem-solving, and written/verbal communication skills.

• Proficiency in Epic or comparable EHR/coding platforms.

• Ability to work independently on complex, escalated coding cases in a production environment.

• Completion of regulatory/mandatory certifications as required.

• Willingness and ability to travel to client or organizational sites as needed.

Preferred - Core

• Bachelor’s degree in Health Information Management or related field.

• Experience mentoring or providing QA feedback to other coders.

Required - PB/ASC

• Strong knowledge of CPT, HCPCS, ICD-10-CM, modifier usage, and NCCI edits as applied to ambulatory surgery center and professional billing services.

Preferred - PB/ASC

• Certified Ambulatory Surgery Center Coder (CASCC) credential.

• Working knowledge of hospital-based (HB) outpatient coding.

Required - Pathology/Radiology

• Strong knowledge of CPT, HCPCS, ICD-10-CM, modifier usage (including professional/technical component splits), and NCCI edits as applied to pathology and radiology services.

Preferred - Pathology/Radiology

• Certified Interventional Radiology Cardiovascular Coder (CIRCC) credential.

• Experience with molecular pathology and genetic testing coding.

Required - Primary Care / ED Profee / HB Outpatient

• Strong knowledge of E/M guidelines (office/outpatient and ED leveling), CPT, HCPCS, and ICD-10-CM coding as applied to primary care, ED professional fee, and/or hospital-based outpatient services.

Preferred - Primary Care / ED Profee / HB Outpatient

• Certified Evaluation and Management Coder (CEMC) credential.

• Experience coding both ED professional fee and hospital-based outpatient encounters.

Physical Demands and Work Environment

Work Environment: Operates in a professional office or remote home office environment, with occasional travel to client or organizational sites as needed.

Physical Demands: This is largely a sedentary role; however, employees may need to use keyboards, mouse, and other devices for typing, clicking, and navigating software systems.

Schedule: Standard business hours with occasional flexibility required to support physician availability or escalated case turnaround.