Outpatient Payment Integrity Production Coder

Position Summary:
MedReview is looking for a Outpatient Payment Integrity Production Coder . The Outpatient Payment Integrity Production Coder is responsible for completing claim-level outpatient coding reviews to identify inaccurate coding, unsupported billing, documentation gaps, and potential overpayments. This role supports payment integrity operations by applying outpatient coding expertise, client payer policy, CMS guidance, CPT/HCPCS requirements, modifier rules, NCCI edits, and medical record documentation standards to ensure audit findings are accurate, defensible, and client savings consistently recovered.

Key Responsibilities

• Perform outpatient coding reviews using medical records, itemized bills, claim lines, payer requirements, CPT/HCPCS guidance, ICD-10-CM guidelines, revenue codes, modifier rules, NCCI edits, APC/EAPG logic, and supporting documentation.

• Validate whether billed outpatient services are supported by documentation and whether the correct procedure codes, modifiers, units, revenue codes, and billing combinations were reported.

• Identify coding discrepancies, unsupported services, unbundling, inappropriate modifier usage, incorrect procedure code selection, unit errors, documentation deficiencies, and other outpatient payment integrity findings.

• Apply approved audit target guidance, job aids, payer policy, coding hierarchy, and documentation standards consistently across assigned claims.

• Document audit rationale clearly and defensibly, including supported findings, unsupported findings, code changes, modifier issues, documentation gaps, and references used to support the review decision.

• Meet production, quality, turnaround time, and general professional expectations while maintaining accuracy and consistency.

• Escalate complex coding, payer policy, reimbursement, pricing, workflow, or documentation questions to the appropriate lead, manager, or subject matter expert.

• Participate in training, calibration reviews, quality feedback sessions, and target refreshers to support consistent application of outpatient audit concepts.

• Maintain current knowledge of outpatient coding guidelines, payer policies, CMS guidance, NCCI edits, LCDs/NCDs, modifier requirements, and reimbursement methodologies relevant to outpatient payment integrity.

Required Qualifications

• Current nonexpired coding certification credential required: CPC, COC, CCS, RHIT, RHIA or equivalent.

• Minimum of 3 years of outpatient coding experience required.

• Strong knowledge of CPT, HCPCS, ICD-10-CM, revenue codes, modifier usage, NCCI edits, outpatient documentation standards, and payer-specific coding requirements.

• Experience reviewing outpatient facility claims, medical records, operative reports, emergency department records, observation records, ancillary services, injections and infusions, surgical procedures, or other outpatient service lines.

• Ability to interpret payer policy, CMS guidance, LCDs/NCDs, coding references, and documentation requirements and apply them to claim-level reviews.

• Ability to distinguish between coding validation and payment integrity auditing by evaluating what was billed, what is supported, and why a billed service may be incorrect or unsupported.

• Strong written communication skills with the ability to document clear, concise, and defensible audit rationale.

• High attention to detail, analytical thinking, sound judgment, and ability to work independently in a production environment.

• Ability to meet productivity and quality expectations while managing multiple claims, priorities, and deadlines.

• Proficiency with Microsoft Outlook, Word, Excel, coding tools, claim review platforms, and electronic medical record documentation systems.

Preferred Qualifications

• Previous payment integrity, audit, outpatient facility audit, payer review, or claims review experience preferred.

• Experience with outpatient reimbursement methodologies such as APC, EAPG, OPPS, multiple procedure reductions, packaging, bundling, and payer-specific reimbursement rules.

• Experience using coding references, encoder tools, 3M, TruCode, WebStrat, payer portals, claim systems, or similar applications.

• Optum platforms experience

Production and Quality Expectations

The Outpatient Payment Integrity Production Coder is expected to complete assigned claims in accordance with approved workflow, target guidance, quality standards, and turnaround time expectations. The coder must maintain accurate notes, apply coding guidance consistently, participate in quality review and calibration activities, and respond to feedback in a timely and professional manner. Production expectations may vary based on claim complexity, target type, medical record size, payer requirements, and training status.

Core Competencies

• Outpatient coding accuracy

• Policy and documentation interpretation

• Clear audit rationale writing

• Production discipline and time management

• Attention to detail

• Adaptability in a growing outpatient audit program

Compliance and Professional Standards

This position requires adherence to company policies, client requirements, confidentiality standards, HIPAA requirements, coding compliance expectations, and professional standards for accurate and ethical claim review. The coder is expected to maintain confidentiality, exercise objective judgment, and support accurate payment outcomes through consistent application of approved coding and audit criteria.