Outpatient payment validation analyst

Job Description: Outpatient Payment Validation Analyst / Revenue Integrity Specialist

Department: Revenue Cycle / Payment Integrity

Reports To: Manager, Payment Validation & Clinical Audits

Role Summary

We are seeking a highly analytical Outpatient Payment Validation Analyst to ensure accurate reimbursement for outpatient facility claims. This role requires strong expertise in coding, payment methodologies, and grouper logic to validate claim payments, identify variances, and support revenue integrity.

Core Competencies

Candidates must have solid knowledge of:

• OPPS: Medicare outpatient payment rules, status indicators, Composite APCs, device-dependent procedures.
• APC: Understanding of code-to-APC mapping and reimbursement impact.
• EAPG: Experience with 3M™ EAPG logic, including packaging, consolidation, discounting, and significant procedures.
• Grouper Logic: Ability to use grouper tools to analyze and troubleshoot claim assignments.

Key Responsibilities

• Validate outpatient claims, APC/EAPG assignments, NCCI edits, MUEs, and OCE logic.
• Identify payment variances from incorrect coding, missing modifiers, or charge capture issues.
• Use grouper software to analyze packaging logic and complexity adjustments (e.g., J1/J2).
• Ensure compliance with payer policies and updates (Medicare, Medicaid, Commercial).
• Review claims against Inpatient Only List and other regulatory requirements.

Qualifications

• Education: Bachelor’s in Healthcare Administration, HIM, Life Sciences, or related field.
• Certifications:
• Required: CPC or COC
• Preferred: CIC or CCS
• Experience: 4+ years in outpatient coding or revenue integrity with OPPS/EAPG auditing experience.
• Familiarity with 3M™ Encoder or similar grouping tools.

Technical Skills

• Strong Excel skills (Pivot Tables, VLOOKUP).
• Understanding of Revenue Codes and payment impact.
• Ability to interpret EOBs and remittance advice.

Job Types: Full-time, Permanent

Pay: Up to ₹700,000.00 per year

Work Location: In person