Medical Coder Pre Claims

Key Responsibilities

• Review orders and supporting documentation to confirm accurate, compliant ICD-10 and CPT/HCPCS coding inputs needed for clean claim submission.
• Identify missing or incomplete claim-critical elements (e.g., ICD-10 codes, patient demographics, insurance details, medical-necessity documentation) and drive timely remediation through established workflows.
• Confirm that documentation and coding elements required to meet payer expectations are in place prior to claim submission, escalating gaps for resolution as needed.
• Execute coding-focused quality checks and proactive audits to detect trends, prevent repeat errors, and reduce downstream denials tied to documentation or coding gaps.
• Contribute to the creation and maintenance of standardized templates and checklists that improve pre-claim readiness (e.g., documentation requirements, coding-integrity checks).
• Partner with front-end operations (eligibility/benefits investigation, prior-authorization workflows, and demographic-accuracy processes) to reduce missing billing information and rework before claims are submitted.
• Collaborate cross-functionally to translate payer requirements into scalable operational practices that support clean claims and consistent outcomes.
• Support visibility into pre-claim performance drivers by tracking and communicating recurring gap themes that impact clean claims and downstream adjudication.
• Align work to key operational metrics used to manage RCM performance (e.g., Missing Billing %, Clean Claim Rate) to reduce bottlenecks before they affect revenue.

Qualifications

• A high school diploma or equivalent; additional education in health sciences or a related field preferred.
• Demonstrated working knowledge of ICD-10-CM and CPT/HCPCS coding concepts as applied to claim-submission readiness.
• Proven ability to identify missing or invalid claim-critical data elements and drive resolution through cross-functional coordination.
• Prior professional coding certification (AAPC/AHIMA or equivalent) preferred.
• Experience supporting pre-claim quality, audits, or denial prevention workflows in a high-volume healthcare revenue cycle environment.