PB Coding Integrity Specialist - Primary Care Specialties

Major Responsibilities

• Analyze and resolve coding-related PB and HB denials using CPT, HCPCS, ICD-10-CM, and modifiers.

• Identify root causes, patterns, and trends in denial and rejection codes.

• Collaborate with billing, coding, and payer teams to correct, resubmit, and prevent denied claims.

• Conduct chart reviews to validate documentation against billed services.

• Prepare and support appeals by researching payer guidelines, coding standards, and coverage policies.

• Ensure accurate, compliant coding and sequencing aligned with official guidelines and payer requirements.

• Track, document, and report denial resolutions, appeal outcomes, and coding quality issues.

• Support compliance, quality assurance, and revenue integrity initiatives through issue monitoring and escalation resolution.

• Educate clinicians, coders, and staff by sharing findings and supporting targeted training based on denial trends.

• Contribute to operational and strategic initiatives, including denial avoidance strategies, work queue optimization, CARC code mapping, and technology-driven improvements.

Minimum Job Requirements

Education

• Associate degree or equivalent education and experience required.

Certification / Registration / License

• Coding credential required. A Coding Certification from American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) with relevant experience.

Experience

• 4 years of experience in expert-level professional coding or hospital-based coding and experience in revenue cycle processes, health information workflows, and medical record auditing experience

Knowledge / Skills / Abilities

• Advanced knowledge of third-party reimbursement programs, state and federal regulatory issues, national and local coverage decisions, research related restrictions, and ICD-10-PCS/CM, CPT, and HCPCS coding classification systems.

• Advanced knowledge of medical terminology, anatomy, and physiology.

• Advanced ability to identify coding discrepancies and provide recommendations for improvement

• Advanced ability to analyze trends and data and display them in a statistical reporting format.

• Advanced knowledge of care delivery documentation systems and related medical record documents.

• Advanced knowledge of Medicare, Medicaid, and commercial payer coding guidelines.

• Advanced knowledge of Microsoft Office, video and web conferencing, email, and experience with electronic coding and EHR systems or applications.

• Advanced interpersonal and communication (oral and written) skills, including the ability to effectively collaborate with multiple departments.

• Advanced organization and prioritization skills; ability to manage multiple priorities in a stressful, fast-paced work environment.

• Advanced analytical skills, with great attention to detail.

• Self-motivated with initiative and strong sense of ethics.

• Ability to work independently and exercise independent judgment and decision making.

• Ability to meet deadlines while working in a fast-paced environment.

• Strong organizational skills and ability to work independently with limited guidance or direction. Effective critical thinking, creativity, problem solving and decision-making skills.

Physical Requirements and Working Conditions

• Position requires travel which will result in exposure to road and weather hazards.

• Operates the equipment necessary to perform the job.

• Exposed to a normal office environment.

Preferred Job Requirements

Preferred Certification / Registration / License

• Second Specialty credential preferred

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.