Revenue Integrity Coding Billing Specialist

Guidehouse•Birmingham, AL

4d•$59,000 - $98,000•Remote

About The Position

The Revenue Integrity Coding Billing Specialist provides revenue cycle support under the direction of the Director of Revenue Integrity. The role reviews and resolves assigned Medicare and third-party payer accounts subject to pre-bill claim edits, hospital billing scrubber bill-hold edits, and claim denials. This position is 100% remote. The specialist resolves assigned claims and Revenue Integrity-specific denials, reviews clinical documentation and diagnostic results when needed, and validates and applies ICD-10, CPT, and HCPCS codes and modifiers. The role also supports compliance with federal and state guidelines and maintains current knowledge of Medicare, Medicaid, and other third-party payer billing requirements. Other duties may be assigned by the Director of Revenue Integrity.

Requirements

High school diploma; relevant experience may be substituted for formal education.
At least 5 years of Revenue Integrity experience.
AAPC or AHIMA coding certification.
Experience with ICD-10, CPT, and HCPCS Level II coding.
Expertise in determining medical necessity based on provider and clinical documentation.
Knowledge and proper application of Medicare, Medicaid, and third-party payer UB-04 billing and reporting requirements, including resolution of CCI, MUE, and medical necessity claim edits.
Proficiency determining accurate medical codes for outpatient diagnoses, procedures, and services, including emergency department and clinic visits, same-day surgeries, diagnostic testing, outpatient therapies, and chemotherapy.
Knowledge of current code-bundling rules and regulations, compliance, and reimbursement under outpatient grouping systems such as Medicare OPPS and Medicaid or commercial insurance EAPGs.
Knowledge and understanding of hospital charge description master coding systems and structures.
Strong verbal, written, and interpersonal communication skills.
Ability to produce accurate assigned work within specified time frames.

Nice To Haves

Five years of experience in Revenue Integrity Coding and Billing.
Hospital medical billing and auditing experience.
Associate's degree.

Responsibilities

Resolve assigned claims with Revenue Integrity pre-bill edits and specific hold codes in the hospital billing scrubber.
Resolve standard billing edits, including Correct Coding Initiative (CCI), Medically Unlikely Edits (MUE), medical necessity edits, and other assigned claim-level edits.
Review clinical documentation and diagnostic results as needed to validate and apply ICD-10, CPT, and HCPCS codes and associated modifiers.
Resolve assigned claims with Revenue Integrity-specific denials in the Guidehouse METRIX℠ system.
Use authoritative information to ensure coding and billing practices comply with federal and state guidelines.
Maintain current knowledge of Medicare, Medicaid, and other third-party payer billing compliance guidelines and requirements.
Perform other duties commensurate with skills and experience as determined by the Director of Revenue Integrity.