Claims Coding Specialist

About the Role

Capitol Bridge Puerto Rico is seeking an experienced Claims Coding Specialist to provide specialized coding and billing analysis for healthcare claim disputes supporting the Florida CDR and multi-state IRO programs. This role serves as the team’s coding subject matter expert, evaluating whether billed services, procedures, modifiers, diagnoses, and related claim information are supported by the submitted record and applicable coding guidance.

Payrate: $22.50/hr

Key Responsibilities

• Review disputed healthcare claims for coding, billing, and documentation issues requiring specialized analysis.
• Evaluate CPT, HCPCS, ICD-10-CM, modifiers, units, and other applicable claim elements against the submitted documentation and relevant guidance.
• Analyze EOBs, claim forms, medical records, billing records, and supporting materials to identify coding discrepancies or documentation gaps.
• Provide objective coding findings to RN reviewers, physicians, attorneys, and program leadership for incorporation into dispute reviews.
• Distinguish coding and billing questions from clinical medical-necessity issues and escalate clinical questions to the appropriate credentialed reviewer.
• Research and apply current governmental and professional coding guidance relevant to the services under review.
• Document coding rationale clearly enough to support review findings, quality review, and auditability.
• Assist with development and maintenance of coding job aids, reference materials, and reviewer guidance as requirements change.
• Participate in Quality Assurance/Quality Control reviews, calibration discussions, training, and complex-case consultation.
• Complete assignments within required turnaround times and comply with privacy, security, project, and company requirements.

Required Qualifications

• Current professional coding certification such as CPC, CCS, CCS-P, or comparable nationally recognized credential.
• At least three years of professional medical coding, claims auditing, reimbursement, or healthcare billing experience.
• Strong working knowledge of CPT, HCPCS, ICD-10-CM, modifiers, EOBs, and healthcare claim documentation.
• Ability to research and interpret coding guidance and document clear, supportable conclusions.
• Strong written and verbal communication skills in English.

Preferred Qualifications

• Experience with healthcare claims disputes, payment appeals, payer auditing, utilization review support, or independent review programs.
• Experience in hospital, physician, facility, or multi-specialty coding environments.
• Experience working with nurses, physicians, attorneys, health plans, and healthcare providers on disputed claims.
• Bilingual English/Spanish communication skills.

What Success Looks Like

Coding questions are resolved consistently and defensibly. Clinical reviewers have a reliable coding resource, coding rationale is clearly documented, and complex billing or coding issues are identified early enough to keep cases moving within required timelines.

Required Screenings

Employment is contingent upon successful completion of applicable background screening requirements.

Reasonable Accommodation

Reasonable accommodation may be made to enable qualified individuals with disabilities to perform the essential functions of this position. Additional duties may be assigned based on program needs.

Equal Employment Opportunity

Capitol Bridge Puerto Rico is an Equal Opportunity Employer. Employment decisions are based on business needs, job requirements, and individual qualifications, without regard to any status protected by applicable law.