Position Overview: This role focuses on hands-on claims review, coding validation, and RCM processes. The Coding Auditor will identify incorrect coding/billing, support denials management, and ensure compliance with payer and CMS guidelines to improve payment accuracy. Specialty Expertise: Evaluation & Management (E/M) Surgery / Anesthesia / Radiology DME Any Medical Coding Specialty Key Responsibilities: Perform manual claims review and identify coding/billing errors Validate CPT, ICD, HCPCS codes, modifiers Support denials management & pre/post payment review Analyze claims using RCM workflows & reimbursement methodologies Flag incorrect claims and recommend corrections Ensure compliance with CMS, NCCI, Medicare/Medicaid guidelines Work on UB-04 / CMS 1500 claims forms Collaborate with internal teams to improve claim accuracy Requirements: • Strong expertise in Medical Coding & RCM processes • Hands-on experience in claims audit and validation • Understanding of coding guidelines, billing workflows, and compliance • Strong domain expertise Semi automated Claims review • Solid understanding of medical coding & billing methodologies and guidelines, including CPT, ICD, LCD/NCD, PTP, NCCI, edits, modifiers, Medicare Physician fee schedule, and coding conventions. • Proficiency in data collection, analysis, and deriving actionable insights from CMS medical policies, Medicaid Provider Manuals and other Medical publications. • Translate industry references into actionable business logic to support new rules and policy enhancements. • Strong understanding of claim forms like UB-04/CMS 1450 and CMS 1500 • Collaborate effectively across teams while managing multiple priorities • Ability to thrive in a fast-paced, dynamic environment with minimal supervision. • Demonstrated mindset for continuous learning and improvement and apply insights to policy development, refinement and maintenance. • Strong stakeholder management, interpersonal, and leadership skills. • Solution-focused, motivated, entrepreneurial spirit with a strong sense of ownership. • Clear and effective communication. • Strong attention to accuracy and detail in all deliverables Qualifications Education & Certification (one of the following required): • Medical Degree (e.g., MBBS, BDS, BPT, BAMS etc) • Nursing: Bachelor/Master of Science in Nursing • Pharmacist Degree (B.Pharm, M.Pharm or PharmD) • Life Science -Bachelor/Master Certification Requirements: • Must hold any of the following certifications: CPC, CPMA, COC, CIC, CPC-P, CCS or any specialty certifications from AHIMA or AAPC. • Additional weightage will be given for AAPC specialty coding certifications. • Lean Six Sigma certification and practical application experience are preferred. Experience: • Experience in Payment Integrity Content/Research, Semi automated Claims Review • 3+ years experience for Analyst • 5+ years experience for TL • 10+ Years for Manager • 13+ years for Senior Manager • Experience in rule requirement Semi automated Claims Review. • Experience in claims review, denials, coding validation Key Skills: • Medical Coding (CPT, ICD, HCPCS) • Claims Audit & Validation • RCM & Denials Management • Knowledge of NCCI edits, modifiers • Nurse claims Review • Attention to detail & analytical skills • Domain Expertise in US Healthcare Medical Coding, Medical Billing, Payment Integrity, Revenue Cycle Management (RCM), Denials Management. • Codeset Knowledge like CPT/HCPCS, ICD, Modifier, DRG, PCS, etc. • Payment Policies knowledge like Medicare/Medicaid Reimbursement, Payer Payment Policies, NCCI, IOMs, CMS Policies etc • High proficiency in Microsoft Word and Excel, with adaptability to new platforms. • Excellent verbal & written communication skills. • Excellent Interpretation and articulation skills • Strong analytical, critical thinking, and problem-solving skills • Willingness to learn new products and tools