Senior Specialist, Clinical Services

Claritev; United States; On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Health insurance

401k

Bonus opportunity

Job summary

Claritev is seeking a Senior Medical Coding Specialist to analyze high-dollar, complex claims while applying coding standards, industry knowledge and federal regulations to ensure correct billing practices.

The role supports global operations, reviews claims for accuracy, and collaborates with international teams to align with international standards and regulations. Strong expertise in ICD-10, CPT, ICD-10-AM and related coding systems is essential.

Qualifications

• Current coding certification (AHIMA or AAPC) or medical license (RN, MD) required.
• 7+ years of experience in a clinically related field including coding, auditing, nursing, radiology, or physician assistant roles.
• Extensive knowledge of inpatient/outpatient hospital billing and international coding terminology.
• Experience with international coding standards and global billing practices.

Responsibilities

• Review and analyze complex inpatient, outpatient, and practitioner billing for medical appropriateness of treatment.
• Design and participate in the clinical and coding education of coders, negotiators, and physicians, incorporating international coding systems.
• Facilitate daily claim completion meetings with coding operations teams, including international counterparts when applicable.
• Drive successful coding operations through continuous professional development and ongoing coding research.
• Collaborate with physician and analytics teams to create, enhance or suggest new coding edits, claim factors, guidelines and other applicable reference materials.
• Monitor, research, and summarize trends, coding practices, and regulatory changes.
• Communicates clinical, coding and reimbursement findings to co-workers and management in a clear, organized manner.
• Partner with management to drive department goals and objectives.
• Ensure compliance with HIPAA regulations and international data protection regulations (e.g., GDPR, PIPEDA).
• Please note due to the exposure of PHI sensitive data – this role is considered to be a High Risk Role.

Skills

Communication skills

Analytical thinking

Problem solving

Cross-cultural communication

Education

AHIMA or AAPC certification / medical license

Tools

Excel

Outlook

PowerPoint

Visio

International billing platforms

Job description

JOB DESCRIPTION The Senior Medical Coding Specialist provides analysis of the highest dollar and most complex claims by applying research, coding standards, industry knowledge and federal regulations to ensure correct billing practices. In this role, the incumbent will perform reviews to identify variations from quality billing practices and monitor bills for accuracy and compliance. This position also requires familiarity with international coding systems and healthcare billing practices to support global operations and ensure alignment with international standards.

Job Summary

JOB DESCRIPTION The Senior Medical Coding Specialist provides analysis of the highest dollar and most complex claims by applying research, coding standards, industry knowledge and federal regulations to ensure correct billing practices. In this role, the incumbent will perform reviews to identify variations from quality billing practices and monitor bills for accuracy and compliance. This position also requires familiarity with international coding systems and healthcare billing practices to support global operations and ensure alignment with international standards.

Job Roles And Responsibilities

• Review and analyze complex inpatient, outpatient, and practitioner billing for medical appropriateness of treatment; analyze charges of various revenue centers with consideration to patient diagnosis, procedures, age and facility type and international healthcare norms where applicable
• Assist management in the daily operations and processes within the department.
• Design and participate in the clinical and coding education of coders, negotiators, and physicians, incorporating international coding systems (e.g., ICD-10-AM, OPCS-4, SNOMED CT). This includes orientation, training and mentoring of new and existing staff.
• Facilitate daily claim completion meetings with coding operations teams, including international counterparts when applicable; discuss complex cases, provide feedback, and initiate new coding protocols.
• Drive successful coding operations through the application of learned, certified knowledge in addition to continuous professional development and ongoing coding research.
• Provide general support to clinical team members, serving as a resource and subject matter expert (SME).
• Monitors turnaround times for multiple applications and provides suggestions for process efficiencies.
• Uses independent decision making skills to review claims after business hours to meet deadlines.
• Apply national and international coding standards and regulations to claims billed.
• Research and review individual claims, claim trends or detailed itemized bills, operative notes and other documentation as needed.
• Collaborate with physician and analytics teams to create, enhance or suggest new coding edits, claim factors, guidelines and other applicable reference materials.
• Monitor, research, and summarize trends, coding practices, and regulatory changes.
• Apply clinical judgment and high level of expertise along with analytic skills in review of the most challenging and difficult cases; including conducting additional research as needed.
• Communicates clinical, coding and reimbursement findings to co-workers and management in a clear, organized manner.
• Evaluate performance of both newly hired and existing staff. .
• Assist with education of staff as it relates to claims, suggest additional negotiation talking points or tools, develop instructional design, when applicable and communicate overall industry or regulatory changes which affect the department.
• Partner with management to drive department goals and objectives.
• Collaborate, coordinate, and communicate across disciplines and departments, and international teams.
• Ensure compliance with HIPAA regulations and international data protection regulations (e.g., GDPR, PIPEDA).
• Demonstrate commitment to the Company’s core values.
• Please note due to the exposure of PHI sensitive data – this role is considered to be a High Risk Role.
• The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

JOB SCOPE

This position works independently with minimal supervision in order to complete the outlined responsibilities. The incumbent balances several projects at a time and work is varied and complex. More complex issues are referred to higher levels. The incumbent follows established procedures and uses knowledge of the Company’s general business principles, industry dynamics, market trends, and specific operational details when performing all aspects of the job.

JOB REQUIREMENTS (Education, Experience, And Training)

• Current Coding certification (AHIMA or AAPC) or medical license (RN, MD) required
• 7+ years of experience in a clinically related field including but not limited to; coding, auditing, nursing, radiology, laboratory, pharmacy, or physician assistant roles.
• Extensive knowledge of inpatient/outpatient hospital billing and claims data including UB-04s, revenue codes, CPT, HCPCS, ICD-10, DRG, APCs, and familiarity with international equivalents (e.g., KSA, ICD-10-AM, ACHI, CCI)
• Extensive knowledge of international medical coding and data resources such as WHO guidelines, CPT assistant, medical association publications supporting medical coding and clinical research websites is required.
• Knowledge of payer reimbursement policies, state and federal regulations, medical necessity criteria and applicable industry standards.
• Auditing and health information management experience in a healthcare setting preferred.
• Experience and proficiency using MS Office Suites: Excel, Outlook and PowerPoint. Visio helpful. Experience with international billing platforms is a plus.
• Excellent communication (written, verbal and listening), interpersonal, organizational, time-management, analytical, problem-solving, trouble-shooting, customer service skills, including cross-cultural communication.
• Ability to develop educational materials and job aids pertaining to coding and claims.
• Ability to work evening or weekend hours as needed to meet deadlines.
• Ability to handle multiple tasks in a fast paced environment.
• Ability to meet individual and team goals, deadlines and work standards.
• Ability to apply independent judgment and determine appropriate course of action.
• Ability to read and abstract medical records.

Compensation

The salary range for this position is $70-90k annually. Specific offers take into account a candidate’s education, experience and skills, as well as the candidate’s work location and internal equity. This position is also eligible for health insurance, 401k and bonus opportunity