Audit and resolve coding, payment integrity, and appeals queues by reviewing medical records, validating CPT/HCPCS/ICD-10-CM codes, applying NCCI/CMS and payer guidelines, and researching disputes. Maintain productivity, quality, SLA targets, document findings, participate in audits, escalate complex cases, recommend process improvements, and ensure HIPAA/OIG compliance.
Skills Required
- Strong analytical and critical-thinking skills
- Excellent medical record review and interpretation skills
- Effective written and verbal communication
- Ability to work independently and manage multiple priorities
- Knowledge of denial management and appeals processes
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Strong problem-solving and research capabilities
Performance Metrics
- Quality Accuracy ≥ 98%
- Achievement of Productivity Targets
- SLA/TAT Adherence
- Compliance with Process and Documentation Standards
- Minimal Audit Defects and Rework
- Review and resolve Code Edit, Provider Payment Integrity (PPI), PCI, and Appeals work queues.
- Analyze medical records, provider documentation, claim history, and coding guidelines.
- Validate CPT, HCPCS, ICD-10-CM, modifiers, and reimbursement methodologies.
- Apply CMS, NCCI, Medicare, Medicaid, and commercial payer editing guidelines.
- Research coding disputes and provide supporting rationale for determinations.
- Maintain productivity, quality, and turnaround time targets.
- Escalate complex coding scenarios and policy interpretation issues appropriately.
- Update productivity, clarification, and audit logs daily.
- Participate in internal and external quality audits.
- Identify trends and recommend process improvements.
- Ensure compliance with HIPAA, OIG, and organizational policies.
- Respond promptly to client and leadership communications.
Qualifications & Experience
- Life Science / Paramedical / Healthcare-related degree
- Active CPC, CCS certification
- Strong knowledge of CPT, HCPCS, ICD-10-CM, NCCI edits, CMS guidelines, and payer policies
- Proficiency in MS Office and healthcare applications
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Willing to work in Eastern (US) shift when required
Experience
- Minimum 2+ years of medical coding experience
- Experience in Surgery, E&M, or Denial Management is mandatory.
- Experience in code edit review, appeals, grievances, provider disputes, or payment integrity programs is an advantage
Working Hours
- Full-time (40 hours per week)
- Shift timing based on business requirements
- Weekends Off (subject to project need)
EXL Chennai, Tamil Nadu, IND Office
Chennai, India
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