Outpatient Payment Integrity Specialist

MedReview Inc.; New York (NY); On-site; USD 58,000 - 65,000; Full time

Job summary

MedReview Inc. is seeking an Outpatient Payment Integrity Production Coder to perform claim-level outpatient coding reviews, ensuring accuracy, defensible audit findings, and client savings. You will apply CPT/HCPCS, ICD-10-CM, NCCI, and CMS guidance to identify overpayments and enforce correct billing practices.

The role requires 3+ years in outpatient coding, CPC/COC/CCS/RHIT/RHIA or equivalent credentials, and strong written communication to document audit rationale and support conclusions.

Qualifications

• Current nonexpired coding certification credential required: CPC, COC, CCS, RHIT, RHIA or equivalent.
• Minimum of 3 years of outpatient coding experience required.
• Strong knowledge of CPT, HCPCS, ICD-10-CM, revenue codes, modifier usage, NCCI edits, outpatient documentation standards, and payer-specific coding requirements.
• Experience reviewing outpatient facility claims, medical records, operative reports, ED records, observation records, ancillary services, injections and infusions, surgical procedures, or other outpatient service lines.

Responsibilities

• Perform outpatient coding reviews using medical records, itemized bills, claim lines, payer requirements, CPT/HCPCS guidance, ICD-10-CM guidelines, revenue codes, modifier rules, NCCI edits, APC/EAPG logic, and supporting documentation.
• Validate whether billed outpatient services are supported by documentation and whether the correct procedure codes, modifiers, units, revenue codes, and billing combinations were reported.
• Identify coding discrepancies, unsupported services, unbundling, inappropriate modifier usage, incorrect procedure code selection, unit errors, documentation deficiencies, and other outpatient payment integrity findings.
• Apply approved audit target guidance, job aids, payer policy, coding hierarchy, and documentation standards consistently across assigned claims.
• Document audit rationale clearly and defensibly, including supported findings, unsupported findings, code changes, modifier issues, documentation gaps, and references used to support the review decision.
• Meet production, quality, turnaround time, and general professional expectations while maintaining accuracy and consistency.
• Escalate complex coding, payer policy, reimbursement, pricing, workflow, or documentation questions to the appropriate lead, manager, or subject matter expert.
• Participate in training, calibration reviews, quality feedback sessions, and target refreshers to support consistent application of outpatient audit concepts.
• Maintain current knowledge of outpatient coding guidelines, payer policies, CMS guidance, NCCI edits, LCDs/NCDs, modifier requirements, and reimbursement methodologies relevant to outpatient payment integrity.

Skills

Outpatient coding

Analytical thinking

Attention to detail

Independent work

Education

CPC/COC/CCS/RHIT/RHIA or equivalent

Tools

3M Encoder

TruCode

WebStrat

MS Office

Job description

MedReview Inc. is seeking an Outpatient Payment Integrity Production Coder to perform claim-level outpatient coding reviews, ensuring accuracy, defensible audit findings, and client savings. You will apply CPT/HCPCS, ICD-10-CM, NCCI, and CMS guidance to identify overpayments and enforce correct billing practices.

The role requires 3+ years in outpatient coding, CPC/COC/CCS/RHIT/RHIA or equivalent credentials, and strong written communication to document audit rationale and support conclusions.