PB Coding Integrity Specialist - Primary Care Specialties
About The Position
The PB Coding Integrity Specialist - Primary Care Specialties role is within the Enterprise Revenue Cycle - Integrity Operations department, focusing on Professional Coding Denials. This is a full-time position eligible for benefits, requiring 40 hours per week, typically Monday through Friday on the first shift. The schedule allows for flexibility in start time after training, between 5 am and 7 pm. The role involves analyzing and resolving coding-related denials, identifying root causes, collaborating with various teams to prevent future denials, and conducting chart reviews. The specialist will also prepare appeals, ensure accurate coding, track resolutions, support compliance initiatives, and educate staff on denial trends. Contributions to operational and strategic initiatives, including denial avoidance and work queue optimization, are expected.
Requirements
- Associate degree or equivalent education and experience required.
- Coding credential required. A Coding Certification from American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) with relevant experience.
- 4 years of experience in expert-level professional coding or hospital-based coding.
- Experience in revenue cycle processes, health information workflows, and medical record auditing experience.
- Advanced knowledge of third-party reimbursement programs, state and federal regulatory issues, national and local coverage decisions, research related restrictions, and ICD-10-PCS/CM, CPT, and HCPCS coding classification systems.
- Advanced knowledge of medical terminology, anatomy, and physiology.
- Advanced ability to identify coding discrepancies and provide recommendations for improvement.
- Advanced ability to analyze trends and data and display them in a statistical reporting format.
- Advanced knowledge of care delivery documentation systems and related medical record documents.
- Advanced knowledge of Medicare, Medicaid, and commercial payer coding guidelines.
- Advanced knowledge of Microsoft Office, video and web conferencing, email, and experience with electronic coding and EHR systems or applications.
- Advanced interpersonal and communication (oral and written) skills, including the ability to effectively collaborate with multiple departments.
- Advanced organization and prioritization skills; ability to manage multiple priorities in a stressful, fast-paced work environment.
- Advanced analytical skills, with great attention to detail.
- Self-motivated with initiative and strong sense of ethics.
- Ability to work independently and exercise independent judgment and decision making.
- Ability to meet deadlines while working in a fast-paced environment.
- Strong organizational skills and ability to work independently with limited guidance or direction.
- Effective critical thinking, creativity, problem solving and decision-making skills.
Nice To Haves
- Second Specialty credential preferred.
Responsibilities
- Analyze and resolve coding-related PB and HB denials using CPT, HCPCS, ICD-10-CM, and modifiers.
- Identify root causes, patterns, and trends in denial and rejection codes.
- Collaborate with billing, coding, and payer teams to correct, resubmit, and prevent denied claims.
- Conduct chart reviews to validate documentation against billed services.
- Prepare and support appeals by researching payer guidelines, coding standards, and coverage policies.
- Ensure accurate, compliant coding and sequencing aligned with official guidelines and payer requirements.
- Track, document, and report denial resolutions, appeal outcomes, and coding quality issues.
- Support compliance, quality assurance, and revenue integrity initiatives through issue monitoring and escalation resolution.
- Educate clinicians, coders, and staff by sharing findings and supporting targeted training based on denial trends.
- Contribute to operational and strategic initiatives, including denial avoidance strategies, work queue optimization, CARC code mapping, and technology-driven improvements.
Benefits
- Comprehensive suite of Total Rewards: benefits and well-being programs
- Competitive compensation
- Generous retirement offerings
- Programs that invest in your career development
- Paid Time Off programs
- Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
- Flexible Spending Accounts for eligible health care and dependent care expenses
- Family benefits such as adoption assistance and paid parental leave
- Defined contribution retirement plans with employer match and other financial wellness programs
- Educational Assistance Program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
