The Senior Clinical Coder serves as a subject matter expert in medical coding and DRG validation, playing a critical role in ensuring coding accuracy, regulatory compliance, and appropriate reimbursement across inpatient and outpatient services.
In this role, you will conduct detailed retrospective claims reviews, provide expert-level coding analysis, and support cross-functional teams including medical directors, claims operations, and quality management. This position is ideal for a highly analytical professional who thrives in a fast-paced, remote environment and is passionate about accuracy, compliance, and continuous improvement in healthcare operations.
Duties & Responsibilities
Serve as a subject matter expert for ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding
Perform DRG validation and retrospective medical claims reviews
Analyze inpatient and outpatient claims for coding accuracy and reimbursement determinations
Prepare clear, detailed determination letters and written review outcomes
Identify coding discrepancies, potential fraud, and quality concerns
Provide training, mentorship, and guidance to clinical coding staff
Collaborate with cross-functional teams to support coding inquiries and review findings
Research and apply medical policies, benefits, limitations, and current coding guidelines
Ensure timely completion of coding reviews in alignment with performance standards
Maintain accurate and thorough documentation within medical management and claims systems
Escalate complex or high-risk cases to the Medical Director as appropriate
Required Qualifications
High School Diploma or GED
Active credential in one of the following:
Certified Coding Specialist (CCS)
Minimum of five (5) years of clinical coding experience (facility and/or professional)
Minimum of three (3) years of inpatient and/or outpatient claims processing experience
Experience working in a fast-paced, production-driven environment
Ability to obtain and maintain a favorable background investigation
Desired Qualifications
Experience within managed care, health insurance, or private healthcare industry
Familiarity with government healthcare programs and regulatory guidelines
Advanced expertise in inpatient facility coding and DRG validation
Strong analytical, critical thinking, and problem-solving skills
High attention to detail with strong organizational capabilities
Ability to manage large volumes of complex information independently
Effective communication and collaboration across multidisciplinary teams
Proficiency in Microsoft Word, Excel, and multi-system environments
Location & Work Type
100% Remote (must reside in an approved state)
Full-time position
Independent home office work environment required
Prolonged computer use and sitting required
Flexibility to support varying work schedules as needed
#J-18808-Ljbffr