APC Coding Validation Specialist

This is a Fully Remote Job 1. About Our Client: The organization operates in the healthcare intelligence industry, focusing on the payment continuum. It addresses challenges related to value, transparency, and efficiency in healthcare payment processes. Serving over 85 health plans, including many top national plans and covering more than 270 million lives, the organization provides a configurable, AI-powered platform combined with specialized expertise. Its solutions aim to improve financial outcomes and reduce healthcare costs at scale. 2. About the Opportunity: The APC Coding Validation Specialist on the Complex Payment Solutions Team is responsible for ensuring accurate and compliant outpatient payment determinations. This role involves validating outpatient coding, billing, and documentation accuracy through detailed medical record reviews. The position directly impacts the organization’s ability to deliver precise reimbursement decisions by applying expert knowledge of coding guidelines and outpatient payment methodologies. 3. Responsibilities: Review billed charges against medical documentation, payer policies, and coding standards to ensure correct reimbursement Apply coding guidelines across a range of outpatient services, including Interventional Radiology, Radiation Oncology, injections, infusions, surgeries, implants, and observation services Utilize knowledge of Medicare outpatient reimbursement methodologies such as OPPS, APC, and EAPG Apply expert knowledge of NCCI edits, modifier usage, CPT, and HCPCS coding guidelines Interpret and apply Medicare LCDs and NCDs Document clear and defensible audit findings that explain reimbursement impact Develop rationales for coding changes based on authoritative sources and payer policies Work independently and collaboratively in a production-driven environment Maintain accuracy, quality, and productivity standards, including proper code assignment and documentation Use Grouper/Pricer software, ICD-10-CM encoders, and Microsoft Office tools Follow AHIMA’s Standards of Ethical Coding Perform additional duties as assigned 4. Requirements: Associate’s or Bachelor’s degree in Health Information Management, Medical Coding, or related field Minimum 2 years of experience in pre-pay or post-pay reimbursement audits Experience auditing outpatient facilities, including specialty areas such as Interventional Radiology, Radiation Oncology, injections and infusions, Behavioral Health, and ambulatory surgery Active certification such as RHIT, RHIA, CCS (AHIMA), or CPC 5-7 years of outpatient facility coding and auditing experience Strong knowledge of ICD-10-PCS/CM, CPT, and HCPCS coding guidelines Expertise in Medicare regulations, including LCDs, NCDs, NCCI edits, OPPS, and APC methodologies Experience with APC payment methodologies, OPPS logic, fee schedules, and payer contracts Proficient verbal and written communication skills High attention to detail and analytical skills Familiarity with auditing tools and encoders such as 3M, TrueBridge, Grouper/Pricer software 5. Pay Range and Compensation Package: Salary range: $85,000 - $100,000, with opportunity for quarterly bonuses Compensation is based on candidate experience, skills, certifications, and qualifications Different levels may be available depending on candidate fit 6. Benefits & Perks: Remote work available throughout the US Medical, dental, and vision insurance Flexible Spending Account (FSA) and Health Savings Account (HSA) options Tuition reimbursement program 401(k) plan with company match Additional health and wellness benefits Flexible and supportive work environment Equal Opportunity Statement: Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin. Note: TalentHop is a recruitment partner of this role. Please note that all employment decisions, including candidate assessment, interviews, hiring, compensation, and employment terms, are made exclusively by the hiring employer.