Certified Medical Coder (Medicare)

Commence•Remote, VA

10d•$58,000 - $78,000•Remote

About The Position

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care. With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care.

Requirements

3+ years of direct experience in medical coding, medical billing, and/or coding quality assurance/auditing in a healthcare environment, including ICD-10-CM/PCS, CPT/HCPCS, and DRG/APR-DRG coding systems.
Active coding certification through AAPC or AHIMA: CPC, CCS, CCS-P, CRC, RHIA, or RHIT.
Ability to research, apply, and document coding determinations in accordance with CMS coverage, coding, and payment rules, including National and Local Coverage Determinations (NCDs/LCDs).
Ability to work independently and productively in a remote, technology-driven, queue-based claims review environment.
Working knowledge of, and ability to comply with, HIPAA and other laws/regulations governing confidentiality and privacy of protected health information (PHI) and personally identifiable information (PII).
Working knowledge of, and ability to comply with, CMS system and information security requirements.
Associate's degree in a related discipline, or an equivalent combination of certification and relevant experience in lieu of a degree.

Nice To Haves

3+ years of Medicare Fee-for-Service (FFS) claim review experience.
Experience with queue-based or low-code/no-code case management systems as an end user.
Prior experience on a CMS program integrity, audit, or medical review contract (e.g., MAC, RAC, UPIC, SMRC).

Responsibilities

Perform coding-focused medical review of Medicare Part A/B and DMEPOS claims for the program.
Apply Medicare policies and guidelines, ensuring claims are evaluated according to National and Local Coverage Determinations and CMS rules, and document clear, accurate findings for each claim.
Compare paid claim information against the provider's clinical documentation – verifying the assigned ICD-10-CM, CPT, and HCPCS codes to confirm coding accuracy, ensure medical necessity, detect overpayments or underpayments, and confirm compliance with Medicare policy.
Perform coding-only medical reviews (no clinical judgment required) on Medicare Part A/B and DMEPOS claims, applying ICD-10-CM/PCS, CPT/HCPCS, and DRG/APR-DRG coding rules.
Research and apply NCDs, LCDs, and CMS coding/payment guidance to render and document coding determinations.
Identify potential improper payments, coding errors, and documentation patterns indicative of fraud, waste, or abuse for referral consideration.
Maintain claim review documentation in the designated case tracking system.
Support claim(s) re-review and provider education sessions as requested.
Maintain individual accuracy score in accordance company standards.
Complete required annual trainings (e.g., ethics, records management, security controls) and maintain HIPAA/PHI compliance.