Claims & Long Term Care Coding Specialist

Work Schedule: M-F; variable work schedule

POSITION SUMMARY

Responsible for managing the lifecycle of claims across multiple specialties, including long-term care services. This role focuses on claim submission, denial management, aging follow-up, and payer resolution while ensuring accurate coding, documentation compliance, and timely reimbursement. Acts as a subject-matter resource for payer requirements, medical necessity, and claims resolution across varied lines of business.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodation may be made to enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statement(s)

v Reviews and validates clinical documentation and progress notes across multiple medical specialties for completeness, accuracy, and medical necessity.

v Applies, validates, and links appropriate CPT, ICD-10, and HCPCS codes in accordance with documentation and payer-specific guidelines.

v Bills and manages claims across multiple specialties.

v Works insurance aging reports to identify unpaid underpaid, or delayed claims; initiates follow-up actions to ensure timely resolution.

v Analyzes and resolves claim denials, rejections, and payment discrepancies; submits corrected claims and appeal with appropriate supporting documentation.

v Performs chart audits and utilization reviews; provides documentation and coding feedback to providers.

v Creates and maintains accurate patient demographics, insurance, authorizations, and eligibility information within EMR and billing systems.

v Communicates with insurance carriers, third-party administrators, and internal teams regarding claim status, policy interpretation, and reimbursement outcomes.

v Ensures compliance with payer contracts, CMS guidelines, and specialty specific billing regulations.

v Maintains up-to-date knowledge of coding updates, insurance policies, and reimbursement changes across all assigned specialties.

v Demonstrates reliable attendance and punctuality.

v Other duties as assigned.

POSITION QUALIFICATIONS

Competency Statement(s)

v Accuracy – Ability to perform work accurately and thoroughly.

v Analytical Skills – Ability to use reasonable thinking to problem solve.

v Communication, Oral – Ability to communicate effectively with others using the spoken word.

v Communication, written – Ability to communicate in writing clearly and concisely.

v Confidentiality – Must maintain strictest confidentiality and comply with all HIPAA regulations and policies.

v Detail Orientated – Ability to pay attention to every detail of a project or task.

v Honesty / Integrity – Ability to be truthful and be seen as credible in the workplace.

v Organized – Possessing the trait of being organized or following a systematic method of performing a task.

v Time Management – Ability to utilize the available time to organize and complete work assignments within given timeframes.

v Working Under Pressure – Ability to complete assigned tasks under strict deadlines.

v Claims Management – Ability to manage high-volume claims across multiple specialties from submission through final resolution.

v Denial Resolution – Ability to interpret EOBs, remittance advice, and payer correspondence to resolve denials efficiently.

v Aging Analysis – Ability to prioritize and work insurance aging reports to reduce AR days and improve cash flow.

v Payer Knowledge – Understanding of payer-specific billing rules, prior authorization requirements, and appeal processes.

v Coding Knowledge – Demonstrates strong working knowledge of CPT, ICD-10, and HCPCS coding across multiple specialties, including long-term care. Ability to apply correct codes in accordance with payer-specific guidelines and identify documentation or coding deficiencies that may impact claim accuracy, reimbursement, or compliance.

Education: High School Diploma, Coding Certification

Experience: One to two years’ related experience

SKILLS & ABILITIES

Computer Skills

Basic knowledge of Microsoft programs (Excel)

Medical practice EMR software experience

Tenkey pad

Certificates & Licenses

Certified Professional Coder

Other Requirements

Medical Terminology

Familiarity with coding and insurance guidelines

Multitasking Ability

Oral and written communication skills

Accurately work multiple Medical EMR systems

Accurately code progress notes and submit clean claims

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