Outpatient Payment Integrity Auditor
United States
Full Time
Experienced
At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions.
The Outpatient Payment Integrity Coder Auditor is responsible for reviewing outpatient medical claims to ensure coding accuracy, compliance, and appropriate payment in accordance with CMS and payer-specific guidelines. This role supports the development and implementation of payment integrity initiatives by identifying coding and billing inaccuracies, trends, and potential cost savings opportunities across outpatient facility claims.
The ideal candidate has advanced knowledge of outpatient coding, APC and EAPG payment methodologies, and clinical documentation requirements, with strong analytical and auditing skills.
Responsibilities
Qualifications/Experience
Required:
Preferred:
Experience
Core Competencies:
Remote Work Requirements
Salary Range: $100,000 - $102,500
The Outpatient Payment Integrity Coder Auditor is responsible for reviewing outpatient medical claims to ensure coding accuracy, compliance, and appropriate payment in accordance with CMS and payer-specific guidelines. This role supports the development and implementation of payment integrity initiatives by identifying coding and billing inaccuracies, trends, and potential cost savings opportunities across outpatient facility claims.
The ideal candidate has advanced knowledge of outpatient coding, APC and EAPG payment methodologies, and clinical documentation requirements, with strong analytical and auditing skills.
Responsibilities
- Perform detailed coding audits on outpatient facility claims to validate appropriate CPT/HCPCS, revenue codes, modifiers, and ICD-10 coding in accordance with CMS, NCCI, and payer-specific rules.
- Evaluate medical record documentation to ensure services are coded, billed, and reimbursed accurately.
- Identify and analyze payment integrity issues including overpayments, underpayments, and incorrect billing patterns.
- Collaborate with clinical, data analytics, and payment integrity teams to develop new outpatient claim review concepts and audit strategies.
- Provide education and feedback to internal teams or providers based on audit findings.
- Research and apply current CMS OPPS, APC, and EAPG guidelines to ensure compliant auditing practices.
- Document audit findings clearly and concisely, maintaining a high standard of accuracy and quality assurance.
- Contribute to the development and testing of audit tools, rule logic, and automated review concepts to enhance outpatient claim accuracy.
- Stay current with regulatory updates, coding changes, and payer policy revisions.
Qualifications/Experience
Required:
- Certified Professional Coder (CPC), Certified Outpatient Coder (COC), or equivalent AHIMA certification (CCS).
- 3+ years of experience in outpatient facility coding, auditing, or payment integrity.
- Strong knowledge of CMS OPPS, APC, and EAPG payment methodologies.
- Proficiency in interpreting medical documentation and applying official coding guidelines.
- Excellent analytical, organizational, and written communication skills.
Preferred:
- Experience with managed care organizations, commercial payer claim reviews, or payment integrity programs.
- Familiarity with data analytics tools and claim review platforms.
- Prior experience in payment integrity, and audit development strongly preferred.
Experience
- At least 3 years of experience in Hospital Outpatient Surgery coding.
- Expertise with reimbursement methodologies.
- Prior experience in payment integrity, and audit development strongly preferred.
- Familiarity with data analytics and audit selection processes.
Core Competencies:
- High attention to detail and coding accuracy
- Critical thinking and investigative mindset
- Integrity and commitment to compliance
- Ability to communicate complex findings effectively
- Continuous learning and adaptability to regulatory changes
Remote Work Requirements
- High speed internet (100 Mbps per person recommended) with secured WIFI.
- A dedicated workspace with minimal interruptions to protect PHI and HIPAA information.
- Must be able to sit and use a computer keyboard for extended periods of time.
- Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents.
- 401(k) with Employer Match - Join the team and we will invest in your future
- Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, to observe holidays.
- Wellness - We care about your well-being. From Commuter Benefits to FSAs we’ve got you covered.
- Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional.
Salary Range: $100,000 - $102,500
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