Claims Professional Jobs in Reston, VA (NOW HIRING)

Healthcare Legal Solutions is seeking an experienced Senior Coding Specialist to support our end-to-end appeals and claims recovery operations. This role will be responsible for ensuring that coding applied to denied and appealed claims is accurate, compliant, and strategically aligned with payer requirements and client expectations. Rather than simply coding high-volume encounters, this position will focus on reviewing complex claims, interpreting documentation and payer policies, advising on appeal strategy, and supporting quality and consistency across our coding and denial management workflows.

The Senior Coding Specialist will have visibility across multiple product lines and venues, including inpatient and outpatient hospital claims, professional services, and specialty service lines, as applicable to client engagements. They will help operationalize coding guidelines, regulatory requirements, and client policies; identify coding-related denial trends; recommend corrective actions; and contribute to process improvements that enhance both recovery outcomes and compliance. This role may also provide guidance and education to internal staff and client teams on documentation standards, coding changes, and payer expectations.

Key Responsibilities

• Review codes already billed based on APR-DRG and MS-DRG for appeal.
• Review denied and underpaid claims to confirm and assign appropriate ICD-10, CPT, HCPCS codes and modifiers, ensuring coding supports appeal arguments and complies with payer and regulatory guidelines.
• Analyze medical records, EOBs, denial and approval letters, and related correspondence to identify coding issues, documentation gaps, and opportunities to overturn denials.
• Interpret and apply Medicare, Medicaid, and commercial payer rules and policies, including NCCI edits and medical necessity requirements, within the appeals and claims recovery process.
• Collaborate with appeals specialists, legal and clinical reviewers, and client revenue cycle teams to clarify documentation, resolve coding questions, and support case strategy.
• Monitor coding-related denial trends, assist in root-cause analysis, and recommend process or documentation changes to reduce future denials.
• Support the development and maintenance of standardized coding procedures, guidelines, and templates in alignment with regulatory requirements and client policies.
• Provide input into operational and performance reports related to coding accuracy, denial overturn rates, and documentation quality.
• Participate in audits and quality reviews; identify coding or documentation errors and contribute to corrective-action plans.
• Assist with onboarding and ongoing training of team members on coding fundamentals, documentation expectations, and relevant policy or regulatory updates.

Qualifications

• Associate or bachelor's degree in a related field preferred; candidates with a high school diploma/GED and strong relevant experience will be considered.
• Current CPC (Certified Professional Coder) or equivalent coding certification required; additional certifications (e.g., CCS, CRC/Risk Adjustment) are preferred.
• Prior experience with health systems, health plans, TPAs, or healthcare legal/consulting organizations, specifically in Coding, Denials/Appeals, or Revenue Cycle Operations.
• Minimum three years of hands-on medical coding experience, with demonstrated proficiency in ICD 10, CPT, HCPCS, and modifier use.
• Familiarity with Medicare and commercial payer regulations, documentation requirements, and third-party payer issues.

• Strong analytical skills with the ability to synthesize documentation, denial codes, and payer policies into clear coding and appeal recommendations.
• Excellent written and verbal communication skills, with the ability to explain coding decisions and documentation needs to both technical and non-technical stakeholders.
• Strong organizational and time-management skills, with the ability to manage multiple priorities, deadlines, and stakeholders in a fast-paced, metrics-driven environment.

Fast learners with solid foundational experience in coding, denials, or healthcare operations are encouraged to apply.