Medical Coding & Reimbursement Specialist

Job Family:

Travel Required:

Clearance Required:

What You Will Do:

We are seeking a Senior Medical Coding & Reimbursement Specialist to support federal health programs by providing expertise in healthcare coding reimbursement provider billing practices and claims this role you will help shape how coding standards reimbursement requirements provider billing workflows and healthcare service relationships are analyzed evaluated and operationalized across clinical operational reimbursement and analytics stakeholders.

You will apply knowledge of CPT HCPCS ICD-10 modifiers revenue codes claims adjudication and reimbursement methodologies to support consistent decision-making improve operational understanding and ensure healthcare services are accurately represented within program processes and supporting frameworks. The ideal candidate brings deep coding and reimbursement expertise combined with an understanding of how healthcare services move from clinical delivery through documentation coding billing adjudication and payment. Responsibilities will include:

• Develop refine and maintain CPT HCPCS ICD-10 modifier revenue code and ancillary service code groupings.

• Support development of code sets that accurately represent episodes of care treatment pathways and healthcare services.

• Research coding guidance Medicare policies reimbursement methodologies and billing requirements to support code inclusion and exclusion decisions.

• Identify related supporting bundled ancillary add-on and downstream services associated with diagnoses and procedures.

• Validate code sets against Medicare requirements fee schedules reimbursement policies NCCI edits and coding standards.

• Review provider billing practices and claims patterns to identify missing duplicative or inappropriate code relationships.

• Document coding rationale business rules assumptions exclusions and validation findings.

• Participate in coding reviews clinical reviews quality control activities and stakeholder reviews.

• Collaborate with clinicians reimbursement SMEs and analytics teams to evaluate code inclusion exclusion and grouping decisions.

• Support governance processes change requests maintenance activities and version control efforts.

What You Will Need:

• 2 years of experience in medical coding reimbursement payment integrity auditing compliance revenue cycle or claims operations.

• Strong knowledge of CPT HCPCS ICD-10-CM ICD-10-PCS revenue codes modifiers Medicare reimbursement methodologies claims adjudication provider billing workflows NCCI edits and fee schedules.

• Experience working within payer provider TPA Medicare Medicaid TRICARE Commercial or Federal healthcare environments.

• Ability to translate coding guidance and reimbursement requirements into operationally actionable code set recommendations.

• Candidates should possess one or more of the following certifications:

  • Certified Professional Coder (CPC)

  • Certified Outpatient Coder (COC)

  • Certified Professional Medical Auditor (CPMA)

  • Certified Risk Adjustment Coder (CRC)

  • Registered Health Information Administrator (RHIA)

  • Registered Health Information Technician (RHIT)

  • Certified in Healthcare Compliance (CHC)

  • Certified Emergency Department Coding Specialist (CEDC)

  • Certified OBGYN Coding Specialist (COBGC)

  • Certified Orthopedic Surgical Coding Specialist (COSC)

What Would Be Nice To Have:

• Experience supporting federal health programs Medicare-based payment models or large payer environments.

• Exposure to authorization utilization management payment integrity or claims analytics initiatives where coding decisions affect operational or financial outcomes.

• Experience working with analytics or technical teams to translate coding and reimbursement logic into business rules validation criteria or operational requirements.

• Familiarity with specialty-specific coding areas such as emergency medicine orthopedics behavioral health womens health durable medical equipment or surgical/procedural services.

What We Offer:

Guidehouse offers a comprehensive total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.

Benefits include:

• Medical Rx Dental & Vision Insurance

• Personal and Family Sick Time & Company Paid Holidays

• Position may be eligible for a discretionary variable incentive bonus

• Parental Leave and Adoption Assistance

• 401(k) Retirement Plan

• Basic Life & Supplemental Life

• Health Savings Account Dental/Vision & Dependent Care Flexible Spending Accounts

• Short-Term & Long-Term Disability

• Student Loan PayDown

• Tuition Reimbursement Personal Development & Learning Opportunities

• Skills Development & Certifications

• Employee Referral Program

• Corporate Sponsored Events & Community Outreach

• Emergency Back-Up Childcare Program

• Mobility Stipend

About Guidehouse

Guidehouse is an Equal Opportunity EmployerProtected Veterans Individuals with Disabilities or any other basis protected by law ordinance or regulation.

Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.

If you have visited our website for information about employment opportunities or to apply for a position and you require an accommodation please contact Guidehouse Recruiting at 1- or via email at . All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.

All communication regarding recruitment for a Guidehouse position will be sent from Guidehouse email domains including @ or . Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by Guidehouse. Note that Guidehouse will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for participation in a recruitment event. Never provide your banking information to a third party purporting to need that information to proceed in the hiring process.

If any person or organization demands money related to a job opportunity with Guidehouse please report the matter to Guidehouses Ethics Hotline. If you want to check the validity of correspondence you have received please contact . Guidehouse is not responsible for losses incurred (monetary or otherwise) from an applicants dealings with unauthorized third parties.

Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.