Outpatient Coding Product Manager

Outpatient Payment Integrity Subject Matter Expert

Position Summary
At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions.
The Outpatient Coding Product Manager serves as a key resource in identifying, analyzing, and developing strategies to ensure accurate and compliant reimbursement for outpatient/professional medical claims review. This role provides expertise in outpatient coding, reimbursement and regulatory compliance to support claim audits, policy interpretation and process improvement.

The Outpatient Coding Product Manager collaborates with audit, analytics and operations teams to validate overpayment opportunities, develop concepts for new reviews and support ongoing education and quality initiatives, and functions as an overall outpatient facility data SME.

Responsibilities

• Provide subject matter expertise in outpatient hospital and professional reimbursement methodologies, especially including APC, EAPG, and other grouper-based methodologies.
• Review and interpret client guidelines and policy, provider contract language, and State and Federal regulations to identify audit opportunities.
• Develop, refine, and validate audit concepts and payment integrity rules to identify inappropriate billing and resulting payment errors.
• Collaborate with product, data analytics and technology teams to design and test outpatient claim selection logic.
• Analyze large volumes of claims data to identify coding trends, billing patterns, and emerging opportunities for new audits.
• Interpret and apply CMS and payer guidelines to ensure regulatory compliance and alignment with current coding standards.
• Support product development initiatives by providing clinical and coding insight throughout the product lifecycle.
• Assist with documentation, training materials, and validation testing for new and updated audit concepts. Champion training for auditors and coders to ensure consistent application of outpatient audit methodologies.
• Review audit findings for selection accuracy and to ensure alignment with regulatory and payer policies.
• Provide input on operational workflows and documentation standards to improve audit efficiency and quality.
• Monitor and communicate regulatory updates affecting outpatient reimbursement.
• Prepare and present findings, reports and recommendations to internal stakeholders.

Qualifications

• Coding Certification is required.
  • RHIT, Certified Outpatient Coder (COC), or similar certification preferred.
  • Certified Professional Coder (CPC) or Apprentice Certified Outpatient Coder (COC-A) accepted.
• Strong analytical and data comprehension skills are required.
• SQL or Python coding experience is desirable.
• Additional clinical background is preferred but not required.

Experience

• At least 5 years of experience in hospital outpatient coding required. Surgical coding is particularly desirable.
• Extensive expertise with various outpatient reimbursement methodologies.
• Knowledge of all payer types including Medicare, Medicaid, and Commercial plans.
• Prior experience in payment integrity and audit development strongly preferred.
• Familiarity with data analytics and audit selection processes.

Skills and Competencies

• CPT, HCPCS, ICD-10 coding principles.
• CMS policies and practices, including NCD’s and LCD’s, NCCI Edits for PTP and MUE, and APC groupers.
• Strong analytical and problem-solving abilities.
• Collaborative mindset and ability to work effectively across cross- functional teams.
• Proficiency in Outlook, Word, Excel, and other applications.
• Excellent written and verbal communication skills.
• Maintain professional credentialed status with approved continuing education programs
• Ability to work independently and can multi-task or transition to different tasks easily.

Remote Work Requirements

• High speed internet (100 Mbps per person recommended) with secured WIFI.
• A dedicated workspace with minimal interruptions to protect PHI and HIPAA information.

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