Certified Medical Coder (Medicare)

About the role

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient processes for program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care. The Certified Coder performs coding-focused medical review of Medicare Part A/B and DMEPOS claims for the program.

Responsibilities

• Perform coding-only medical reviews (no clinical judgment required) on Medicare Part A/B and DMEPOS claims, applying ICD-10-CM/PCS, CPT/HCPCS, and DRG/APR-DRG coding rules.
• Research and apply NCDs, LCDs, and CMS coding/payment guidance to render and document coding determinations.
• Identify potential improper payments, coding errors, and documentation patterns indicative of fraud, waste, or abuse for referral consideration.
• Maintain claim review documentation in the designated case tracking system.
• Support claim(s) re-review and provider education sessions as requested.
• Maintain individual accuracy score in accordance with company standards.
• Complete required annual trainings (e.g., ethics, records management, security controls) and maintain HIPAA/PHI compliance.

Requirements

• 3+ years of direct experience in medical coding, medical billing, and/or coding quality assurance/auditing in a healthcare environment, including ICD-10-CM/PCS, CPT/HCPCS, and DRG/APR-DRG coding systems.
• Active coding certification through AAPC or AHIMA: CPC, CCS, CCS-P, CRC, RHIA, or RHIT.
• Ability to research, apply, and document coding determinations in accordance with CMS coverage, coding, and payment rules, including National and Local Coverage Determinations (NCDs/LCDs).
• Ability to work independently and productively in a remote, technology-driven, queue-based claims review environment.
• Working knowledge of, and ability to comply with, HIPAA and other laws/regulations governing confidentiality and privacy of protected health information (PHI) and personally identifiable information (PII).
• Working knowledge of, and ability to comply with, CMS system and information security requirements.
• Associate's degree in a related discipline, or an equivalent combination of certification and relevant experience in lieu of a degree.

Preferred Qualifications

• 3+ years of Medicare Fee-for-Service (FFS) claim review experience.
• Experience with queue-based or low-code/no-code case management systems as an end user.
• Prior experience on a CMS program integrity, audit, or medical review contract (e.g., MAC, RAC, UPIC, SMRC).

Work Environment

The work environment and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. This is a remote position. While performing the duties of this job, the employee regularly works in a climate-controlled environment. Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods of time. Occasionally required to stand, walk, use hands and fingers, kneel or crouch.