(Senior) Coding Specialist

• Review and apply regulatory coding guidelines to ensure accurate and compliant claims processing

• Investigate and resolve coding and claims issues, escalating complex matters as appropriate

• Review, edit, and adjudicate pended or denied claims in HealthLink (Epic) using Claim Edit Software (CES), regulatory guidance, and internal policies

• Research and resolve coding-related appeals by reviewing medical documentation and collaborating with Medical Directors, Pharmacy, and Medical Management

• Analyze billing and coding data to identify trends, outliers, and potential high-risk billing practices

• Conduct data analysis and reporting to support claim edits, denial trends, and leadership insights

• Respond to coding-related inquiries from providers, members, and internal teams through ServiceNow and CRM platforms

• Develop and deliver coding education and training for providers, leadership, and internal teams

• Collaborate with cross-functional teams-including Payment Integrity, Medical Management, SIU, Contracting, Benefits, Customer Success, Marketing, and Provider Reimbursement Configuration-to ensure coding compliance

• Stay current on industry trends, regulatory updates, and coding best practices

Additional Responsibilities for Senior-Level Candidates

• Lead the implementation and oversight of regulatory coding guidelines and complex coding initiatives

• Serve as a subject matter expert (SME) for high-risk or complex coding scenarios

• Research, validate, and optimize claim edit logic, business rules, and system configurations; test outcomes and guide improvements

• Partner with the Special Investigation Unit (SIU) to identify, investigate, and address aberrant billing practices and patterns

• Lead or significantly contribute to coding policy, procedure, and claim edit strategy development

• Drive strategy for coding education, provider communication, and internal training initiatives

• Mentor and support mid-level team members and provide guidance on complex coding decisions

• Coding Specialist:

• • High School Equivalency & 1 Year of Relevant Experience

• • Completion of a Medical Coding Program

• • Certifications in CPC, COC, RHIT, RHIA, CCA, and/or CCS

• Senior Coding Specialist:

• • Bachelor's degree with 2 years of relevant experience

Or

• • Associate's degree with 5 years of relevant experience

Or

• • High School Equivalency with 8 years of relevant experience

• • Completion of a Medical Coding Program

• • Certifications in CPC, COC, RHIT, RHIA, CCA, and/or CCS