POSITION OVERVIEW
The Senior Medical Coder is responsible for ensuring billing accuracy across the client's DME, sleep lab, and physician practice entities. This role reviews and strengthens billing processes, audits coding against clinical documentation, and analyzes error trends to guide corrective action across practices. As a senior coder, this person is also expected to lead audits, mentor other coders, and serve as the subject-matter expert on sleep medicine and DME coding for the program.
KEY RESPONSIBILITIES
Billing Process Review & Optimization
- Review the end-to-end billing process across all physician practice entities to identify gaps and opportunities to increase billing accuracy.
- Partner with Insurance Verification, Prior Authorization, Charge Entry, and Payment Posting teams to close process gaps that lead to coding-related denials.
- Recommend and help implement workflow improvements that reduce rework, delays, and claim rejections.
Coding Audits & Quality Assurance
- Audit CPT, ICD-10-CM, and HCPCS Level II codes against chart notes and clinical documentation to confirm accuracy and medical necessity.
- Review physician E/M coding for sleep medicine visits to confirm level of service is supported by documentation.
- Validate modifier usage and confirm compliance with payer-specific LCD/NCD requirements relevant to sleep medicine.
Trend Analysis & Reporting
- Track and analyze billing error trends by entity, provider, code set, and denial reason.
- Prepare and present regular billing accuracy reports to the physician practices, summarizing findings and root causes.
- Deliver actionable recommendations to practices and internal teams to reduce recurring errors, including documentation improvement guidance and targeted provider education.
- Partner with RCM leadership to monitor whether recommended corrective actions are improving accuracy over time.
Compliance & Coding Standards
- Ensure coding practices align with CMS guidelines and payer-specific policies applicable to sleep medicine and DME.
- Maintain compliance with HIPAA and other regulatory requirements in all coding review activities.
- Stay current on annual CPT, ICD-10-CM, and HCPCS updates relevant to sleep medicine, pulmonology, and DME billing.
Leadership & Cross-Functional Support
- Lead coding audits and quality checks, and mentor other coders and billing staff on accurate coding practices.
- Serve as the go-to subject-matter expert for coding questions across departments and physician practices.
- Support onboarding and training of new coding and billing staff on sleep medicine and DME coding standards.
QUALIFICATIONS
- Active CPC (Certified Professional Coder) credential required; CCS or additional specialty certification a plus.
- Minimum 5 years of medical coding experience, with direct experience in sleep medicine, pulmonology, and/or DME billing strongly preferred.
- Strong working knowledge of CPT, ICD-10-CM, and HCPCS Level II coding systems.
- Demonstrated experience auditing codes against chart notes/clinical documentation for accuracy and compliance.
- Experience with sleep study coding, documentation and billing requirements, including relevant modifiers and medical necessity standards is preferred.
- Proficiency with EHR/practice management systems and Microsoft Excel or Google Sheets for trend reporting.
- Strong written and verbal communication skills, with the ability to present findings and recommendations clearly to physician practices.
- Analytical mindset with the ability to identify patterns in billing error data and translate them into practical recommendations.
CORE COMPETENCIES
- Attention to Detail
- Analytical & Critical Thinking
- Coding & Regulatory Knowledge
- Communication & Influence
- Process Improvement Orientation
- Integrity & Compliance Mindset
- Collaboration
- Coaching & Knowledge-Sharing
