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Role Summary

The Senior Clinical Coder serves as a subject matter expert in medical coding and DRG validation, playing a critical role in ensuring coding accuracy, regulatory compliance, and appropriate reimbursement across inpatient and outpatient services.

In this role, you will conduct detailed retrospective claims reviews, provide expert-level coding analysis, and support cross-functional teams including medical directors, claims operations, and quality management. This position is ideal for a highly analytical professional who thrives in a fast-paced, remote environment and is passionate about accuracy, compliance, and continuous improvement in healthcare operations.

Duties & Responsibilities

• Serve as a subject matter expert for ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding

• Perform DRG validation and retrospective medical claims reviews

• Analyze inpatient and outpatient claims for coding accuracy and reimbursement determinations

• Prepare clear, detailed determination letters and written review outcomes

• Identify coding discrepancies, potential fraud, and quality concerns

• Provide training, mentorship, and guidance to clinical coding staff

• Collaborate with cross-functional teams to support coding inquiries and review findings

• Research and apply medical policies, benefits, limitations, and current coding guidelines

• Ensure timely completion of coding reviews in alignment with performance standards

• Maintain accurate and thorough documentation within medical management and claims systems

• Escalate complex or high-risk cases to the Medical Director as appropriate

Required Qualifications

• High School Diploma or GED

• Active credential in one of the following:

  • Certified Inpatient Coder (CIC)

  • Certified Coding Specialist (CCS)

  • Registered Health Information Technician (RHIT)

• Minimum of five (5) years of clinical coding experience (facility and/or professional)

• Minimum of three (3) years of inpatient and/or outpatient claims processing experience

• Experience working in a fast-paced, production-driven environment

• Ability to obtain and maintain a favorable background investigation

• U.S. Citizenship required

Desired Qualifications

• Experience within managed care, health insurance, or private healthcare industry

• Familiarity with government healthcare programs and regulatory guidelines

• Advanced expertise in inpatient facility coding and DRG validation

• Strong analytical, critical thinking, and problem-solving skills

• High attention to detail with strong organizational capabilities

• Ability to manage large volumes of complex information independently

• Effective communication and collaboration across multidisciplinary teams

• Proficiency in Microsoft Word, Excel, and multi-system environments

Location & Work Type

100% Remote (must reside in an approved state)Full-time position

• Independent home office work environment required

• Prolonged computer use and sitting required

• Flexibility to support varying work schedules as needed