Specialist, Clinical Services

JOB SUMMARY: The Medical Coding Specialist is responsible for providing billing analysis of claims and applying coding standards and federal regulations to ensure correct billing practices. In this role, you will perform bill and chart reviews to identify any variation from quality billing practices and monitor patient bills for accuracy and compliance. This position also requires awareness of international coding systems and healthcare billing practices to support global operations and ensure alignment with international regulatory standards.

JOB ROLES AND RESPONSIBILITIES:

1. Review and analyze inpatient, outpatient, and provider billing for medical appropriateness of treatment; analyze charges across various revenue centers with consideration to patient diagnosis, procedures, age, facility type, and international healthcare norms where applicable.

2. Apply recommendation of national coding and international coding and regulation standards (e.g., ICD-10-AM, OPCS-4, SNOMED CT) to claims billed.

3. Prepare clear, concise and legible findings, including documentation that may be used in cross-border audits or international compliance reviews.

4. Research, review and provide internal response based on receipt of itemized bills, claims, operative notes and other documentation, including those from international providers or translated medical records.

5. Assist with, create or enhance internal claim and review recommendations.

6. Communicate with co-workers and management regarding clinical and reimbursement findings.

7. Assist with clinical education of staff as it relates to clinical aspects of claims, suggesting additional negotiation talking points or tools, and communicating overall industry or regulatory changes which affect the department.

8. Monitor, research, and summarize trends, coding practices, and regulatory changes across multiple countries or regions.

9. Research and review individual claims, claim trends or detailed itemized bills, operative notes and

   1. other documentation as needed.

10. Collaborate, coordinate, and communicate across disciplines and departments.

11. Ensure compliance with HIPAA and international data protection regulations (e.g., GDPR, PIPEDA).

12. Demonstrate commitment to the Company's core values.

13. Please note due to the exposure of PHI sensitive data - this role is considered to be a High Risk Role.

14. The position responsibilities outlined above are in no way to be construed as all encompassing.

    1. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

Job Scope: This position works independently with general supervision in order to complete the outlined responsibilities. The incumbent balances several projects at a time and work is varied and complex. Complex issues are referred up to higher levels. The incumbent will use 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):

• Minimum completion of educational curriculum required of medical license or coding certification held with Bachelor's Degree preferred; or minimum Bachelor's Degree in healthcare related field and at least 2 years of coding experience.

• Current nursing certification and/or current certified coder (CCS, CCS-P or CPC), Registered Health Information Technician (RHIA/RHIT).

• Minimum 2 years experience in direct patient care, medical procedure billing, medical insurance auditing, line item review, audits, coding, and/or reimbursement.

• Knowledge of inpatient/outpatient hospital billing requirements including UB-04s, revenue codes, CPT, HCPCS, ICD-9/10, DRG, APCs, and familiarity with international equivalents (e.g., KSA, ICD-10-AM, ACHI, CCI).

• Knowledge of professional claim billing requirements including HCFA 1500s, CPT codes and ICD-9/ICD-10 diagnoses codes, as well as international claim forms.

• Knowledge of payer reimbursement policies, state and federal regulations, international healthcare systems, and global medical necessity criteria.

• Familiarity with international medical data resources and coding tools.

• Auditing and health information management experience in a healthcare setting preferred.

• Excellent communication (verbal and written), teamwork, training, presentation, negotiation and organizational skills, including cross-cultural communication.

• Proficiency in MS Office Suite and database software; experience with international billing platforms is a plus.

• Ability to handle multiple tasks in a fast paced environment.

• Ability to read and abstract medical records.

• Knowledge of medical terminology, anatomy, and physiology.

• Ability to interact and discuss audit results with providers.

• Required licensures, professional certifications, and/or Board certifications as applicable.

• Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone

COMPENSATION
The salary range for this position is $26.09-$40.16 per hour. 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.

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