APC Coding Validation Specialist

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 85 health plans, including many of the top 20, and representing more than 270 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.

About the Opportunity:

As a Coding Validation Specialist on the Complex Payment Solutions Team, you will play a critical role in performing comprehensive outpatient payment validation reviews. Leveraging your expertise in coding guidelines, outpatient reimbursement methodologies, and regulatory requirements, you will ensure accurate and compliant payment determinations.

In this role, you will review medical records to validate the accuracy of coding, billing, and supporting documentation for outpatient services, including APCs, EAPGs, CPT, and HCPCS Level II codes. You will clearly document audit findings and provide well-supported rationales, citing applicable payer policies, coding guidelines, and industry-standard references.

This position requires exceptional attention to detail, expert-level proficiency in ICD-10-CM/PCS, CPT, and HCPCS coding guidelines, and a strong understanding of outpatient reimbursement methodologies.

What you’ll do:

• Conduct comprehensive reviews to validate the accuracy of billed charges against medical documentation, payer policies, coding guidelines, and industry standards to ensure appropriate reimbursement.
• Apply coding guidelines across a broad range of outpatient services, including but not limited to Interventional Radiology, Radiation Oncology, injections and infusions, outpatient surgeries, implants, and observation services (including carve-outs).
• Demonstrate a strong working knowledge of outpatient reimbursement methodologies, including Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classification (APC), and Enhanced Ambulatory Patient Grouping (EAPG).
• Apply expert-level knowledge of NCCI edits, including appropriate modifier usage, as well as CPT and HCPCS coding guidelines.
• Interpret and apply Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
• Produce clear, concise, and defensible audit findings that accurately articulate reimbursement impact.
• Develop and apply well-supported rationales for coding changes impacting reimbursement, referencing appropriate sources such as AMA Official Coding Guidelines, CPT Assistant, AHA Coding Clinic, payer policies, and other industry-standard resources.
• Work effectively both independently and collaboratively within a production-driven environment.
• Maintain established accuracy, quality, and productivity standards, including correct code assignment and thorough documentation of review outcomes.
• Utilize computer applications and tools, including Grouper/Pricer software, ICD-10-CM encoders, and Microsoft Office products.
• Adhere to the Standards of Ethical Coding as established by AHIMA.
• Perform additional duties as assigned.

What experience you bring (Role Requirements)  

• Associate’s or Bachelor’s degree in Health Information Management, Medical Coding, or a related field
• At least 2 years of experience performing pre-pay and/or post-pay reimbursement audits
• Broad outpatient facility auditing experience, including specialty areas such as Interventional Radiology, injections and infusions, Radiation Oncology, Behavioral Health, and ambulatory surgery
• Active certification including RHIT, RHIA, CCS (AHIMA), and/or CPC
• 5-7 years of experience in outpatient facility coding/auditing
• Sound knowledge of ICD-10-PCS/CM, CPT, and HCPCs coding guidelines
• Experience performing pre- and post-payment reimbursement audits
• Expertise in Medicare regulations, including LCDs, NCDs, NCCI edits, OPPS, and APC methodologies
• Demonstrated experience with APC payment methodologies, OPPS reimbursement logic, fee schedules, and payer contracts
• Excellent verbal and written communication skills
• Strong attention to detail and analytical skills
• Experience with encoder and auditing tools (e.g., 3M, TrueBridge, Grouper/Pricer Software)