Coding & Billing Specialist

Accountabilities:

• Submit accurate, timely, and compliant claims using appropriate CPT, HCPCS, ICD-10 codes, modifiers, and applicable billing requirements.
• Track and resolve claim denials, rejections, and underpayments through investigation, follow-up, correction, and resubmission.
• Validate patient eligibility, authorizations, and appropriate billing pathways for individual encounters.
• Ensure accurate application of telehealth, social determinants of health, preventive care, and other relevant coding requirements.
• Coordinate with credentialing teams, partner operations, and payer representatives to resolve billing and compliance issues.
• Review provider documentation and assign accurate codes in accordance with ICD-10-CM, CPT, HEDIS, and quality reporting guidelines.
• Identify documentation deficiencies and coding gaps, escalating issues and issuing coding queries when additional clarification is required.
• Support provider education and documentation improvement initiatives under the direction of the Coding Manager.
• Assist with the development, implementation, and testing of documentation macros, encounter templates, and coding workflows.
• Maintain and improve internal billing rules covering payer requirements, state-specific regulations, provider types, modifiers, and billing pathways.
• Collaborate with Data & Analytics teams to monitor claim trends, documentation compliance, accounts receivable performance, and other revenue cycle metrics.
• Partner with Revenue Cycle and Clinical Operations teams to align billing processes with payer requirements and organizational objectives.
• Support provider training, compliance education, workflow updates, and other initiatives that improve coding and billing accuracy.
• Adapt to evolving responsibilities as the organization expands into new markets, payer models, and healthcare initiatives.

Requirements:

• AAPC Certified Professional Coder (CPC) certification is required, with credentials subject to verification before an employment offer.
• 3–5 years of professional experience in physician medical billing and coding; pediatric experience is strongly preferred.
• Strong working knowledge of CPT, HCPCS, ICD-10, HEDIS, Medicaid, and commercial payer requirements.
• Proficiency with Athenahealth or similar electronic medical record systems and Microsoft Excel.
• Demonstrated understanding of medical claims workflows, coding compliance, eligibility, authorizations, and denial management.
• Strong attention to detail and the ability to identify coding, documentation, and billing discrepancies accurately.
• Analytical and problem-solving skills, with the ability to investigate claim trends and determine appropriate corrective actions.
• Strong communication and collaboration skills, with the ability to work effectively with providers, operational teams, data specialists, and external payer stakeholders.
• Ability to manage multiple priorities in a fast-paced environment while maintaining accuracy and meeting deadlines.
• Adaptable and comfortable working in an evolving organization where priorities, workflows, and responsibilities may change quickly.
• Passion for improving healthcare outcomes and supporting children with complex medical needs.
• Experience with telehealth billing, value-based care, capitation models, multi-state billing, or quality measures is a plus.
• Experience working in pediatrics, internal medicine, startups, or other rapidly evolving healthcare environments is advantageous.

Benefits:

• Annual salary range of $55,000–$65,000 USD, with compensation determined based on job-related knowledge, skills, experience, and other relevant factors.
• Annual bonus incentive opportunity.
• Competitive medical, dental, and vision insurance.
• Healthcare and Dependent Care Flexible Spending Accounts.
• Company-funded Health Savings Account.
• 401(k) plan with a 4% employer match, fully vested from day one.
• Employer-paid short-term and long-term disability coverage.
• Life insurance equal to 1x annual salary.
• 20 days of PTO, plus 10 company holidays and 2 floating holidays.
• Paid new-parent leave.
• Eligibility to participate in an employee equity purchase programme, where applicable.
• Additional benefits may be available and will be detailed as part of the offer.
• Opportunity to contribute to a mission-driven healthcare environment focused on improving care and support for children with complex medical needs.
• Collaborative, values-driven culture emphasizing trust, innovation, empathy, and diverse perspectives.