APC Coding Validation Specialist

About the Opportunity

As a Coding Validation Specialist on the Complex Payment Solutions Team, you will play a critical role in performing comprehensive outpatient payment validation reviews. Leveraging your expertise in coding guidelines, outpatient reimbursement methodologies, and regulatory requirements, you will ensure accurate and compliant payment determinations.

In this role, you will review medical records to validate the accuracy of coding, billing, and supporting documentation for outpatient services, including APCs, EAPGs, CPT, and HCPCS Level II codes. You will clearly document audit findings and provide well-supported rationales, citing applicable payer policies, coding guidelines, and industry-standard references.

This position requires exceptional attention to detail, expert-level proficiency in ICD-10-CM/PCS, CPT, and HCPCS coding guidelines, and a strong understanding of outpatient reimbursement methodologies.

What you'll do

• Conduct comprehensive reviews to validate the accuracy of billed charges against medical documentation, payer policies, coding guidelines, and industry standards to ensure appropriate reimbursement.
• Apply coding guidelines across a broad range of outpatient services, including but not limited to Interventional Radiology, Radiation Oncology, injections and infusions, outpatient surgeries, implants, and observation services (including carve-outs).
• Demonstrate a strong working knowledge of outpatient reimbursement methodologies, including Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classification (APC), and Enhanced Ambulatory Patient Grouping (EAPG).
• Apply expert-level knowledge of NCCI edits, including appropriate modifier usage, as well as CPT and HCPCS coding guidelines.
• Interpret and apply Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).