The Senior Specialist, Coding Research supports Payment Integrity Prepay operations by researching correct coding edit inquiries, analyzing edit outcomes, validating coding rationale, and monitoring savings and accuracy trends within assigned scope. This role partners with Health Plans, vendors, and internal stakeholders to support consistent application of coding guidelines, timely issue resolution, savings integrity, and accurate claim edit outcomes.

Essential Job Duties:

• Serve as the primary subject matter expert and Health Plan point of contact for assigned state(s), Health Plans, or edit categories.

• Research, analyze, and support correct coding edit accuracy and savings for assigned work.

• Apply state, federal, industry, and vendor coding guidance when researching correct coding edit outcomes.

• Review edit outcomes and coding rationale to identify inconsistencies, risks, savings impact, and improvement opportunities.

• Monitor coding-related trends, savings indicators, and performance outcomes to identify potential variations.

• Support day-to-day triage and resolution of coding edit inquiries impacting assigned work.

• Assist in resolving coding edit questions, savings inquiries, and escalations from Health Plans and internal teams.

• Partner with prepay editing vendors and internal stakeholders to research inquiries and clarify coding edit expectations.

• Communicate coding insights, edit findings, and savings-related observations to internal stakeholders and Health Plan partners.

• Provide recommendations to improve consistency, edit accuracy, and coding outcome quality.

• Support development of job aids, training materials, and team guidance related to correct coding edit accuracy.

• Apply subject matter knowledge to support coding edit processes, initiatives, and accurate outcomes.

Job Requirements:

• Associate’s Degree or equivalent work experience.

• 3–5+ years of coding, payment integrity, or claims experience in a healthcare setting.

• Experience supporting coding accuracy, correct coding edit review, savings analysis, and operational workflows.

• Active and unrestricted coding certification, such as CPC, CCS, CCS-P, RHIT, or equivalent.

Preferred Qualifications:

• Bachelor’s Degree in Business, Healthcare, or a related field.

• Experience in prepayment coding programs and payer environments.

• Exposure to working with coding vendors and Health Plan partners.

• Familiarity with state-specific coding and reimbursement guidelines.

• Proficiency in Excel for tracking, reporting, and trend identification.