Payment Integrity Coding Analyst

The Payment Integrity Coding Analyst provides expert support in medical coding compliance claims adjudication accuracy and coding system integrity. This role ensures that claims processing systems accurately reflect industry-standard coding requirements including CPT HCPCS ICD-9 ICD-10 and related code sets. The analyst supports implementation of regulatory and policy changes evaluates coding-related claim issues and identifies billing trends and errors. The position partners with internal stakeholders and external vendors to maintain coding system functionality and ensure accurate reimbursement and compliance outcomes.

MINIMUM QUALIFICATIONS:

Education Experience or Equivalent Combination:

• Completion of Medical Coding Program with certification (AAPC or AHIMA equivalent: CPC CCA CCS) or ability to obtain within one year
• Minimum 2 years of coding experience across multiple patient visit types
• Experience in claims processing and medical billing within healthcare or insurance settings
• Experience with HMO fully insured indemnity and government programs

• Demonstrated ability to make independent decisions in claim coding and adjudication

Licensure/ Registration/ Certification:

• CPC CCA CCS or equivalent (required or obtained within one year from date of hire)

Knowledge Skills and Abilities:

• Strong knowledge of CPT HCPCS ICD-10 revenue codes and claim formats (837P/837I)
• Understanding of medical terminology anatomy physiology and disease processes
• Knowledge of Coordination of Benefits (COB) rules including Medicare regulations
• Experience using claims processing systems encoder tools and coding software
• Strong analytical problem-solving and trend analysis skills
• Solid organizational and planning capabilities
• Proficient in Microsoft tools and data analysis

• Ability to communicate effectively with internal stakeholders and external parties

PREFERRED QUALIFICATIONS:

Education Experience or Equivalent Combination:

• Bachelors degree in a related field
• 5 years of experience in the healthcare industry

Licensure/ Registration/ Certification:

• Advanced or specialty coding certifications preferred

Knowledge Skills and Abilities:

• Experience with claims processing systems

• Strong familiarity with coding governance reimbursement methodologies and audit processes

ESSENTIAL DUTIES:

(50%) Coding Compliance & Claims Adjudication

• Review and evaluate claims for coding accuracy and medical appropriateness
• Approve or deny claims based on coding guidelines and policy requirements
• Resolve claim processing errors related to code validation during adjudication Ensure compliance with HIPAA and industry coding standards across all claim types

(20%) Coding System Management & Updates

• Monitor CMS NUBC and other regulatory bodies for coding updates
• Support implementation testing and validation of coding system updates
• Maintain and support coding systems including vendor-managed platforms (e.g. ClaimCheck)

• Ensure system configuration aligns with current coding requirements

(20%) Analysis Research & Trend Identification

• Analyze coding-related claim issues to identify billing trends errors and opportunities
• Recommend enhancements or corrections for identified billing trends errors and opportunities
• Conduct research to support new code implementation or policy changes
• Evaluate coding business rules and recommend enhancements or corrections

• Perform trend analysis to support business decision-making

(10%) Stakeholder Support & Communication

• Serve as subject matter expert for coding questions across the organization
• Act as key point of contact for claims provider appeals and adjustment requests
• Communicate coding review outcomes to members and providers when appropriate
• Support cross-functional teams including claims sales and contracting