APC Coding Validation Specialist

Job Details

Experienced

California Office - Roseville, CA

Fully Remote

Full Time

High School

$85000.00 - $100000.00 Salary/year

None

Day

Insurance

APC Coding Validation Specialist

Who We Are

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 60 health plans, including many of the top 20, and representing more than 160 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

Location: This role is full remote

About the Opportunity

At Machinify, we’re constantly reimagining what’s possible in our industry—creating disruptively simple, powerfully clear ways to maximize our clients’ financial outcomes today and drive down healthcare costs tomorrow. As part of the Complex Payment Solutions team, you will, as an APC Coding Validation Specialist, review provider medical records to validate accuracy of billed Ambulatory Payment Classification (APC) and/or Enhanced Ambulatory Patient Group (EAPG) . This role involves reviewing medical records to ensure the accuracy of coding, billing, and documentation related to APCs, EAPGs, CPT, and HCPCS Level II codes. The CVS will report findings, communicate results, ensure compliance with regulatory and client requirements, and maintain quality and productivity standards.

What you’ll do

Performs comprehensive analysis and review of claim information and associated medical records to validate the billed procedure and service codes are accurate and support the assigned APC or Outpatient payment.

Maintains expert knowledge of CPT and HCPCS level II coding conventions and rules, Official Coding Guidelines and American Medical Association (AMA) Coding Clinic and ICD-10 diagnosis coding including remaining updated on changes to coding guidelines, industry trends, and best practices.

Analyze, review, and resolve coding issues related to reimbursement, compliance, and client specific policies.

Validates patient data by comparing claims data received with the patient medical records.

Develops and/or applies the appropriate rationale for any coding change that affects the coding, or the APC or EAPG assignment to include supporting references such as Official Coding Guidelines, AMA Coding guidelines, Medicare or Medicaid Billing Manual, coding and reporting guidelines, and coding conventions.

Analyzes claim and supporting documentation for all claim characteristics impacting reimbursement.

Maintains accuracy, quality, and production standards set by management and clients relating to the identification of incorrect coding, assignment of correct codes, and appropriate documentation of review outcomes.

Ability to use computer applications, Grouper/Pricer software, ICD-10-CM encoder software, and Microsoft Office products.

Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association.

What experience you bring (Role Requirements)

REQUIRED QUALIFICATIONS:

High School Diploma or Equivalent GED

National certification as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Procedural Coder (CPC) and/or Certified Coding Specialist (CCS).

Minimum of five years hospital outpatient coding for PPS reimbursement or at least 2 years’ experience performing APC validation.

Comprehensive knowledge of the APC structure and regulatory requirements.

Excellent oral and written communication skills.

Strong analytic and critical thinking skills.

Able to work independently as well as part of a team in a production environment.

PREFERRED QUALIFICATIONS:

Associate or Bachelors degree in health information management, Medical Coding, or related field.

At least 2 years performing post-adjudication/pre-pay or post-payment APC validation

Well-rounded APC experience including specialty coding such as interventional radiology, infusions, radiation oncology, behavioral health, surgeries, etc.

Experience coding or reviewing EAPG claims

What Success Looks Like…

After 3 months

You will have a strong understanding of the role.

You begin building relationships and collaborating with peers.

You develop effective time and priorities management.

You receive initial feedback about your performance and are using it to improve.

You’ve gained confidence in your abilities and are starting to feel more comfortable in your role.

After 1 year

You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency.

You have established a strong network of internal relationships and are recognized as a key collaborator.

You’ve been entrusted with greater responsibility indicating the company’s confidence in your abilities.

You see opportunities for career progression and personal development.

Pay range: $85,000-$100,000 USD

This is an exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee’s geographic location.

What’s in it for you

PTO, Paid Holidays, and Volunteer Days

Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts

Tuition Reimbursement

Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.

Remote and hybrid work options

What values we’ll share with you

Ask why

Think big

Be humble

Optimize for customer impact

Deliver results

At Machinify, we’re reimagining a simpler way forward. This begins with our employees. We are innovators who value integrity, teamwork, accuracy, and flexibility. We do the right thing, and we listen to the needs of our clients and their members. As tenured experts with unmatched experience, we champion diverse perspectives that help us to better understand and serve our clients.

Our values come to life through our culture. We embrace flexible working arrangements that allow our employees to bring innovation to life in the way that best suits their productivity. We work cross-functionally, abandoning silos, to bring innovative, accurate solutions to market. We invest in each other through ongoing education and team celebrations, and we give back to our communities through dedicating days for volunteering. Together, Machinify is making healthcare work better for everyone, and we’re passionate about a future with better outcomes for all.

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer.

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