Senior Manager, Clinical Coding Applications
4L Data Intelligence™
- United States
- United States
About
Our Mission USE THE POWER OF INTEGR8 AI RISK DETECTION™ TECHNOLOGY FOR GOOD by helping healthcare payers and providers, governments and insurers reduce billions of dollars in out-of-control costs, increase automation and elevate service quality by improving data, provider, payment and decision integrity.
About the Role We are seeking a highly skilled Code Edit & Coding Integrity Expert (Manager) to serve as the company’s subject matter authority on billing code edits, CMS coding updates, and their application to advanced technology solutions. This position plays a critical role in driving continuous improvement of the 4L FWA Prevention™ Solution, ensuring accurate and timely implementation of diagnosis, procedure, and episode-of-care code content to support high-integrity reimbursement and regulatory compliance.
Key Responsibilities Coding Expertise & Solution Development Serve as the company expert on billing codes and code-edit related content, updates, and applications to inform continuous technical development and improvement of the 4L FWA Prevention™ Solution. Analyze, validate, and apply coding guidelines and principles to product solutions. Stay current with CMS coding guidelines for both outpatient and inpatient settings. Validate current CMS-related code edits within the 4L FWA Prevention solution. Consult with customers and internal team members to support day-to-day execution and application of advanced code edits. Clinical Coding & Record Review Review and analyze patient medical record documentation to abstract clinical data and accurately identify/capture diagnostic and procedural information using ICD-10-CM and ICD-10-PCS classification systems. Review patient encounters for accurate assignment of diagnoses, procedures, and/or modifiers. Group diagnoses into appropriate MS-DRGs, including accurate identification and application of Present on Admission (POA) indicators for all inpatient diagnoses. Understand and apply code assignments that may trigger Patient Safety Indicators (PSIs) and maintain familiarity with the most common PSIs. Maintain working knowledge of DRG methodology to support inpatient encounter coding. Quality Assurance, & Compliance Monitor compliance with CMS coding guidelines, OIG regulations, and internal standards. Troubleshoot and independently assist with analysis of system or coding-related issues. Maintain strict adherence to HIPAA at all times. Maintain working knowledge of applicable Federal, State, and Local laws and regulations, company Standards of Conduct, Code of Ethics, and related policies to ensure professional, ethical, and compliant behavior.
Qualifications Required Extensive knowledge of CMS coding guidelines (inpatient and outpatient). Advanced proficiency in ICD-10-CM, ICD-10-PCS, DRG/MS-DRG assignment, and POA indicators. Strong understanding of reimbursement integrity, compliance requirements, and code editing principles. Demonstrated ability to interpret clinical documentation and apply accurate diagnosis and procedure coding. Experience collaborating with technical/product teams on coding or code-edit application. Proven analytical and problem-solving skills, including independent troubleshooting. Excellent communication skills for both internal and customer consultation. Preferred Prior experience in fraud, waste, and abuse (FWA) prevention, payment integrity, or claims analytics. Familiarity with AI-enabled code editing or risk detection solutions. Certification such as CCS, CPC, RHIA, RHIT, or equivalent.
Why Join Us? At 4L Data Intelligence, you’ll be part of a mission-driven team tackling some of healthcare’s biggest challenges through innovative technology. This role offers a unique opportunity to influence product strategy, enhance reimbursement integrity, and improve outcomes for customers across the healthcare ecosystem.
Languages
- English
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