APC Coding Validation Specialist

Machinify

4h•Remote

About The Position

As a Coding Validation Specialist on the Complex Payment Solutions Team, you will play a critical role in performing comprehensive outpatient payment validation reviews. Leveraging your expertise in coding guidelines, outpatient reimbursement methodologies, and regulatory requirements, you will ensure accurate and compliant payment determinations. In this role, you will review medical records to validate the accuracy of coding, billing, and supporting documentation for outpatient services, including APCs, EAPGs, CPT, and HCPCS Level II codes. You will clearly document audit findings and provide well-supported rationales, citing applicable payer policies, coding guidelines, and industry-standard references. This position requires exceptional attention to detail, expert-level proficiency in ICD-10-CM/PCS, CPT, and HCPCS coding guidelines, and a strong understanding of outpatient reimbursement methodologies.

Requirements

Associate’s or Bachelor’s degree in Health Information Management, Medical Coding, or a related field
At least 2 years of experience performing pre-pay and/or post-pay reimbursement audits
Broad outpatient facility auditing experience, including specialty areas such as Interventional Radiology, injections and infusions, Radiation Oncology, Behavioral Health, and ambulatory surgery
Active certification including RHIT, RHIA, CCS (AHIMA), and/or CPC
5-7 years of experience in outpatient facility coding/auditing
Sound knowledge of ICD-10-PCS/CM, CPT, and HCPCS coding guidelines
Experience performing pre- and post-payment reimbursement audits
Expertise in Medicare regulations, including LCDs, NCDs, NCCI edits, OPPS, and APC methodologies
Demonstrated experience with APC payment methodologies, OPPS reimbursement logic, fee schedules, and payer contracts
Excellent verbal and written communication skills
Strong attention to detail and analytical skills
Experience with encoder and auditing tools (e.g., 3M, TrueBridge, Grouper/Pricer Software)

Responsibilities

Conduct comprehensive reviews to validate the accuracy of billed charges against medical documentation, payer policies, coding guidelines, and industry standards to ensure appropriate reimbursement.
Apply coding guidelines across a broad range of outpatient services, including but not limited to Interventional Radiology, Radiation Oncology, injections and infusions, outpatient surgeries, implants, and observation services (including carve-outs).
Demonstrate a strong working knowledge of outpatient reimbursement methodologies, including Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classification (APC), and Enhanced Ambulatory Patient Grouping (EAPG).
Apply expert-level knowledge of NCCI edits, including appropriate modifier usage, as well as CPT and HCPCS coding guidelines.
Interpret and apply Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
Produce clear, concise, and defensible audit findings that accurately articulate reimbursement impact.
Develop and apply well-supported rationales for coding changes impacting reimbursement, referencing appropriate sources such as AMA Official Coding Guidelines, CPT Assistant, AHA Coding Clinic, payer policies, and other industry-standard resources.
Work effectively both independently and collaboratively within a production-driven environment.
Maintain established accuracy, quality, and productivity standards, including correct code assignment and thorough documentation of review outcomes.
Utilize computer applications and tools, including Grouper/Pricer software, ICD-10-CM encoders, and Microsoft Office products.
Adhere to the Standards of Ethical Coding as established by AHIMA.
Perform additional duties as assigned.