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Position Summary:

The Senior Certified Professional Coder– Payment Integrity (PI) is a strategic leader responsible for identifying, evaluating, and preventing incorrect coding practices in our health plan. This role leverages deep expertise in medical coding and commercial reimbursement to build robust detection concepts, manage external vendors, and influence payment policy development. The ideal candidate will operate as a thought leader, collaborating across departments to enhance payment integrity controls and achieve PI financial targets.

 

Key Responsibilities:

Payment Integrity Strategy 

• Act as a trusted advisor to Curative stakeholders, providing thought leadership on program integrity strategies and correct coding initiatives.

• Develop and implement policies, procedures, and frameworks to enhance program integrity and prevent, detect, and recover improper claims payments.

• Collaborate with claims, finance, compliance, and legal teams to refine payment processes and policies. Oversee audits, investigations, and compliance reviews to ensure program adherence to Curative policies and procedures.

Payment Integrity Program Execution 

• Conduct / oversee advanced-level claim and medical record reviews to detect incorrect billing practices; including upcoding, unbundling, duplicate billing, and medically unnecessary services.

• Interpret and apply commercial payer reimbursement rules, provider contract terms, and coding guidelines to assess payment accuracy.

• Manage and oversee relationships with external vendors performing identification, audits, or overpayment recovery services.

• Influence internal and external payment policy by identifying coding vulnerabilities, recommending policy changes, and participating in policy review committees.

• Develop and validate pre-payment and post-payment edit logic; contribute to analytics model refinement.

• Collaborate with compliance, legal, provider relations, and clinical teams to drive resolution and recovery strategies.

• Educate internal teams on emerging schemes, coding trends, and payer rule interpretations.

• Represent Payment Integrity in interdepartmental projects and strategic initiatives.

• Mentor and guide Curative team members; contribute to continuous improvement initiatives across Payment Integrity.

 

Education:

• Required Certification: CPC, CCS, or equivalent medical coding credential.

• Preferred Certifications: CPMA, CRC, or CFE.

• Bachelor’s degree in Health Information Management, Nursing, Healthcare Administration, or related field (or equivalent experience).

Qualifications:

• 7+ years of experience in medical coding, claims auditing, or payment integrity within a commercial payer or vendor environment, with demonstrated success identifying and resolving provider billing anomalies.

• In-depth knowledge of CPT, HCPCS, ICD-10-CM/PCS, NCCI edits, and commercial billing policies.

• Proven experience managing third-party vendors and ensuring performance standards in audit or coding operations.

• Strong understanding of correct coding guidelines and regulatory guidance, including AMA, CMS, and payer-provider contractual dynamics.

• Ability to develop or influence internal payment policy and participate in coding governance decisions.

• Advanced analytical and investigative skills; proficiency with platforms such as Optum CES, HealthEdge, or similar.

• Excellent communication skills with the ability to present findings to both technical and executive audiences.

• Demonstrated leadership in cross-functional collaboration and policy/process improvement.