Coordinator1-Medical

Job Title: Medical Coding & Payment Reimbursement Reviewer

Location: Remote
Job Type: Term-to-Perm
Schedule: Monday–Friday, 8:30 AM–5:00 PM
Experience: Preferably 3–5 years of relevant experience
Compensation: Competitive, based on experience
Equipment: To be confirmed

Job Overview

We are seeking a detail-oriented and analytical Medical Coding & Payment Reimbursement Reviewer to conduct retrospective payment reviews and evaluate healthcare reimbursement decisions. This role involves analyzing medical claims, reviewing Explanations of Benefits (EOBs), identifying payment discrepancies, interpreting payer denials, and determining appropriate reimbursement based on coding guidelines, payer policies, and contractual requirements.

The ideal candidate has a strong background in medical coding, revenue cycle management, and reimbursement analysis, along with the ability to interpret complex coding scenarios and communicate clear, well-supported decisions. Excellent analytical skills, sound judgment, and strong written communication are essential for success in this role.

Key Responsibilities

Retrospective Payment Review

• Conduct retrospective reviews of healthcare claims and reimbursement determinations.

• Analyze payment records to identify discrepancies, underpayments, overpayments, recoupments, and claim adjustments.

• Evaluate supporting documentation to determine appropriate reimbursement.

• Apply relevant coding guidelines, payer policies, and contractual requirements when reviewing payment decisions.

Medical Coding and EOB Analysis

• Review and interpret Explanations of Benefits (EOBs), including denials, corrections, recoupments, and other claim adjustments.

• Evaluate CPT codes, ICD-10-CM diagnosis codes, HCPCS codes, and CPT modifiers.

• Assess how modifiers and code combinations affect reimbursement outcomes.

• Apply knowledge of coding guidelines across multiple medical specialties.

• Identify coding inconsistencies, billing errors, and potential reimbursement discrepancies.

Revenue Cycle and Reimbursement Analysis

• Apply knowledge of revenue cycle management, including claims submission, payment posting, denial management, appeals, accounts receivable, and underpayment identification.

• Review reimbursement methodologies and contractual payment requirements.

• Analyze reimbursement trends and identify opportunities for payment accuracy and revenue recovery.

• Evaluate complex claims and develop objective, evidence-based reimbursement determinations.

Documentation and Written Determinations

• Prepare clear, accurate, professional, and well-supported payment determination letters.

• Explain the rationale behind reimbursement decisions using relevant coding guidance, payer policies, and supporting documentation.

• Ensure all findings and decisions are documented thoroughly and consistently.

• Maintain accuracy, impartiality, and attention to detail when preparing final determinations for distribution to clients and disputing parties.

Compliance and Regulatory Awareness

• Follow applicable medical coding standards, billing requirements, and reimbursement policies.

• Maintain awareness of relevant healthcare regulations and compliance requirements.

• Apply knowledge of the No Surprises Act and its implications for healthcare billing and payment disputes, where applicable.

• Protect confidential healthcare and financial information.

Required Qualifications

• Preferably 3–5 years of experience in medical coding, medical billing, reimbursement analysis, claims review, or revenue cycle management.

• Active or recognized medical coding certification, such as:

  • Certified Professional Coder (CPC) through AAPC.

  • Certified Coding Specialist (CCS) through AHIMA.

• Strong knowledge of CPT, ICD-10-CM, and HCPCS coding systems.

• Understanding of CPT modifiers and their impact on reimbursement.

• Demonstrated experience reviewing and interpreting EOBs, payer denials, recoupments, and claim adjustments.

• Strong understanding of healthcare revenue cycle management and reimbursement methodologies.

• Ability to analyze complex claims, identify discrepancies, and make well-supported payment determinations.

• Excellent written communication skills, including the ability to prepare formal, evidence-based determination letters.

• Strong analytical thinking, critical reasoning, and problem-solving abilities.

• Exceptional attention to detail, accuracy, and organizational skills.

• Ability to manage multiple assignments and meet deadlines in a fast-paced environment.

Preferred Qualifications

• Experience conducting retrospective payment reviews or healthcare reimbursement dispute reviews.

• Broad knowledge of CPT coding across multiple provider specialties.

• Experience with underpayment identification, contract compliance, denial management, appeals, and revenue recovery.

• Familiarity with the No Surprises Act and related payment dispute processes.

• Experience evaluating complex reimbursement scenarios and preparing formal payment determinations.

• Associate degree from an accredited college or university.

Education Requirements

• High school diploma or GED required.

• Associate degree preferred.

• Medical coding certification from a recognized organization, such as AAPC or AHIMA, is required.