PB Coding Integrity Specialist - Primary Care Specialties

Major Responsibilities  

• Analyze and resolve coding-related PB and HB denials using CPT, HCPCS, ICD-10-CM, and modifiers. 

• Identify root causes, patterns, and trends in denial and rejection codes. 

• Collaborate with billing, coding, and payer teams to correct, resubmit, and prevent denied claims. 

• Conduct chart reviews to validate documentation against billed services. 

• Prepare and support appeals by researching payer guidelines, coding standards, and coverage policies. 

• Ensure accurate, compliant coding and sequencing aligned with official guidelines and payer requirements. 

• Track, document, and report denial resolutions, appeal outcomes, and coding quality issues. 

• Support compliance, quality assurance, and revenue integrity initiatives through issue monitoring and escalation resolution. 

• Educate clinicians, coders, and staff by sharing findings and supporting targeted training based on denial trends. 

• Contribute to operational and strategic initiatives, including denial avoidance strategies, work queue optimization, CARC code mapping, and technology-driven improvements.  

Minimum Job Requirements 

Education

• Associate degree or equivalent education and experience required. 

Certification / Registration / License 

• Coding credential required. A Coding Certification from American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) with relevant experience. 

Experience

• 4 years of experience in expert-level professional coding or hospital-based coding and experience in revenue cycle processes, health information workflows, and medical record auditing experience   

Knowledge / Skills / Abilities

• Advanced knowledge of third-party reimbursement programs, state and federal regulatory issues, national and local coverage decisions, research related restrictions, and ICD-10-PCS/CM, CPT, and HCPCS coding classification systems. 

• Advanced knowledge of medical terminology, anatomy, and physiology. 

• Advanced ability to identify coding discrepancies and provide recommendations for improvement 

• Advanced ability to analyze trends and data and display them in a statistical reporting format. 

• Advanced knowledge of care delivery documentation systems and related medical record documents.  

• Advanced knowledge of Medicare, Medicaid, and commercial payer coding guidelines. 

• Advanced knowledge of Microsoft Office, video and web conferencing, email, and experience with electronic coding and EHR systems or applications. 

• Advanced interpersonal and communication (oral and written) skills, including the ability to effectively collaborate with multiple departments. 

• Advanced organization and prioritization skills; ability to manage multiple priorities in a stressful, fast-paced work environment. 

• Advanced analytical skills, with great attention to detail. 

• Self-motivated with initiative and strong sense of ethics. 

• Ability to work independently and exercise independent judgment and decision making.  

• Ability to meet deadlines while working in a fast-paced environment. 

• Strong organizational skills and ability to work independently with limited guidance or direction. Effective critical thinking, creativity, problem solving and decision-making skills. 

Physical Requirements and Working Conditions

• Position requires travel which will result in exposure to road and weather hazards. 

• Operates the equipment necessary to perform the job. 

• Exposed to a normal office environment. 

Preferred Job Requirements 

Preferred Certification / Registration / License 

• Second Specialty credential preferred 

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.