Clinical Coder & Medical Biller

The Member Experience Clinical Coder & Medical Biller is integral to internal medical billing review, payment integrity, and claims adjudication. The role involves reviewing, validating, and repricing claims to ensure accurate reimbursement and support payment integrity for self-insured clients. Responsibilities include translating medical diagnoses, procedures, and services into standardized coding compliant with established guidelines and reimbursement methodologies. Collaboration with providers, TPAs, and other stakeholders to identify coding discrepancies, provide analysis, and communicate findings for optimal claim outcomes is essential.

Key duties include:

• Analyze and verify patient medical records for accuracy to ensure proper billing and adjudication.
• Assign and sequence medical codes according to government, payer, and insurance regulations.
• Identify and follow up on missing or inaccurate data with claims staff, attorneys, or physicians.
• Validate coding decisions and advocate corrections for denied or misprocessed claims.
• Review claims including diagnostic tests, consultations, procedures, treatments, and medications for appropriate coding and billing.
• Analyze complex claims and malpractice scenarios to identify relevant diagnoses and procedures.
• Collaborate with claims examiners to ensure processing accuracy and payment alignment.
• Maintain strict adherence to coding guidelines, payer policies, and regulatory requirements.
• Monitor coding trends to identify risks or improvement opportunities.
• Collaborate with internal teams to resolve coding issues and support member/provider satisfaction.
• Contribute to workflow improvements, best practices, policy updates, and training materials.
• Keep organized, compliant documentation and prepare reports on coding discrepancies and denial trends.