APC Coding Validation Specialist

Machinify • Roseville, CA

81d • $85,000 - $100,000

About The Position

At Machinify, we’re constantly reimagining what’s possible in our industry—creating disruptively simple, powerfully clear ways to maximize our clients’ financial outcomes today and drive down healthcare costs tomorrow. As part of the Complex Payment Solutions team, you will, as an APC Coding Validation Specialist, review provider medical records to validate accuracy of billed Ambulatory Payment Classification (APC) and/or Enhanced Ambulatory Patient Group (EAPG). This role involves reviewing medical records to ensure the accuracy of coding, billing, and documentation related to APCs, EAPGs, CPT, and HCPCS Level II codes. The CVS will report findings, communicate results, ensure compliance with regulatory and client requirements, and maintain quality and productivity standards.

Requirements

• High School Diploma or Equivalent GED
• National certification as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Procedural Coder (CPC) and/or Certified Coding Specialist (CCS).
• Minimum of five years hospital outpatient coding for PPS reimbursement or at least 2 years’ experience performing APC validation.
• Comprehensive knowledge of the APC structure and regulatory requirements.
• Excellent oral and written communication skills.
• Strong analytic and critical thinking skills.
• Able to work independently as well as part of a team in a production environment.

Nice To Haves

• Associate or Bachelors degree in health information management, Medical Coding, or related field.
• At least 2 years performing post-adjudication/pre-pay or post-payment APC validation.
• Well-rounded APC experience including specialty coding such as interventional radiology, infusions, radiation oncology, behavioral health, surgeries, etc.
• Experience coding or reviewing EAPG claims.

Responsibilities

• Performs comprehensive analysis and review of claim information and associated medical records to validate the billed procedure and service codes are accurate and support the assigned APC or Outpatient payment.
• Maintains expert knowledge of CPT and HCPCS level II coding conventions and rules, Official Coding Guidelines and American Medical Association (AMA) Coding Clinic and ICD-10 diagnosis coding including remaining updated on changes to coding guidelines, industry trends, and best practices.
• Analyze, review, and resolve coding issues related to reimbursement, compliance, and client specific policies.
• Validates patient data by comparing claims data received with the patient medical records.
• Develops and/or applies the appropriate rationale for any coding change that affects the coding, or the APC or EAPG assignment to include supporting references such as Official Coding Guidelines, AMA Coding guidelines, Medicare or Medicaid Billing Manual, coding and reporting guidelines, and coding conventions.
• Analyzes claim and supporting documentation for all claim characteristics impacting reimbursement.
• Maintains accuracy, quality, and production standards set by management and clients relating to the identification of incorrect coding, assignment of correct codes, and appropriate documentation of review outcomes.
• Ability to use computer applications, Grouper/Pricer software, ICD-10-CM encoder software, and Microsoft Office products.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association.

Benefits

• PTO, Paid Holidays, and Volunteer Days
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
• Remote and hybrid work options

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 1,001-5,000 employees