APC Coding Validation Specialist

Responsibilities

• Conduct comprehensive reviews to validate the accuracy of billed charges against medical documentation, payer policies, coding guidelines, and industry standards to ensure appropriate reimbursement.
• Apply coding guidelines across a broad range of outpatient services, including but not limited to Interventional Radiology, Radiation Oncology, injections and infusions, outpatient surgeries, implants, and observation services (including carve-outs).
• Demonstrate a strong working knowledge of outpatient reimbursement methodologies, including Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classification (APC), and Enhanced Ambulatory Patient Grouping (EAPG).
• Apply expert-level knowledge of NCCI edits, including appropriate modifier usage, as well as CPT and HCPCS coding guidelines.
• Interpret and apply Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
• Produce clear, concise, and defensible audit findings that accurately articulate reimbursement impact.
• Develop and apply well-supported rationales for coding changes impacting reimbursement, referencing appropriate sources such as AMA Official Coding Guidelines, CPT Assistant, AHA Coding Clinic, payer policies, and other industry-standard resources.
• Work effectively both independently and collaboratively within a production-driven environment.
• Maintain established accuracy, quality, and productivity standards, including correct code assignment and thorough documentation of review outcomes.
• Utilize computer applications and tools, including Grouper/Pricer software, ICD-10-CM encoders, and Microsoft Office products.
• Adhere to the Standards of Ethical Coding as established by AHIMA.
• Perform additional duties as assigned.

Requirements

• Associate’s or Bachelor’s degree in Health Information Management, Medical Coding, or a related field.
• At least 2 years of experience performing pre-pay and/or post-pay reimbursement audits.
• Broad outpatient facility auditing experience, including specialty areas such as Interventional Radiology, injections and infusions, Radiation Oncology, Behavioral Health, and ambulatory surgery.
• Active certification including RHIT, RHIA, CCS (AHIMA), and/or CPC.
• 5-7 years of experience in outpatient facility coding/auditing.
• Sound knowledge of ICD-10-PCS/CM, CPT, and HCPCS coding guidelines.
• Experience performing pre- and post-payment reimbursement audits.
• Expertise in Medicare regulations, including LCDs, NCDs, NCCI edits, OPPS, and APC methodologies.
• Demonstrated experience with APC payment methodologies, OPPS reimbursement logic, fee schedules, and payer contracts.
• Excellent verbal and written communication skills.
• Strong attention to detail and analytical skills.
• Experience with encoder and auditing tools (e.g., 3M, TrueBridge, Grouper/Pricer Software).

Compensation

Pay range: $85,000 - $100,000, with the opportunity to earn quarterly bonuses. Salary based on experience, skills, certifications, etc.