Sr. Clinical Coder
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Summary:
Under the direction of the DRG Supervisor or designee, the Medical Claims Coding Specialist conducts retrospective medical claims review for coding and pricing determinations, focusing on both outpatient and inpatient services. As a subject matter expert, this role provides coding-related information to various departments and functions as the designated recipient for factual network provider claim review requests.
Responsibilities:
- Serve as the subject matter expert on ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding of medical claims.
- Lead coding projects as directed by Clinical Operations management.
- Provide training and mentoring for new and existing Clinical Coders.
- Perform DRG Validation of medical claims coding using current coding guidelines and support software.
- Conduct focused outpatient and/or inpatient claims reviews and summarize findings.
- Identify and report potential fraudulent or quality issues.
- Act as a resource for TriWest staff on coding queries.
- Research TRICARE manuals to assist with the Referral and Authorization Decision Support tool process.
- Monitor timeliness of retrospective claims reviews to ensure compliance with required timelines.
- Prepare determination notices and other written correspondence.
- Identify questionable review decisions and escalate to the appropriate Medical Director.
- Provide accurate data entry in the medical management and claims system.
- Review and document coding issues identified by the TRICARE Quality Monitoring Contractor.
- Perform other duties as assigned, ensuring regular and reliable attendance.
Qualifications:
- High School Diploma or GED.
- Current certification as Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), or Registered Health Information Technician (RHIT).
- U.S. Citizenship required.
- Ability to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation.
- Minimum 5 years of clinical coding experience for facility and/or professional accounts.
- Minimum 3 years of claims processing experience for inpatient and/or outpatient accounts.
- Documented experience in a fast-paced environment.
- Preferred experience in the private medical industry, health insurance, or Managed Care field.
- Familiarity with TRICARE and the military healthcare delivery system is preferred.
- Advanced knowledge of ICD-10-CM, ICD-10 PCS, HCPCS, and CPT coding; proficiency with Word and Excel.
- Strong problem-solving, organizational, and communication skills.
- Ability to function in a multi-system Microsoft environment.
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Why Work with Us
At Cook Systems, we don’t just offer jobs—we build futures. Our people are at the heart of everything we do, and we’re committed to supporting you with benefits that deliver real security, flexibility, and growth from day one.
- Your Health, Your Way: Choose from two comprehensive medical plans through Blue Cross Blue Shield, with dental and vision coverage included. With access to one of the nation’s largest provider networks, you’ll have quality care wherever life takes you.
- Peace of Mind: Protect what matters most with life, critical illness, and accident insurance through Unum—because your family’s security matters.
- Flexibility for Life: Plan ahead and save with a Flexible Spending Account and Daycare FSA through Navia, helping you manage healthcare and dependent-care expenses your way.
- Extra Protection When You Need It: Our Health Gap Insurance through Sun Life helps cover unexpected costs, so you’re never caught off guard.
- Your Future Starts Now: Build your future with our 401(k) plan through The Standard. You’re eligible after just six months—because long-term success deserves a strong foundation.
At Cook Systems, you’re not just an employee—you’re part of a team that values ideas, celebrates results, and grows together. Here, your impact is visible, your contributions are valued, and your career has room to thrive. Ready to be part of something bigger? Let’s build the future together at Cook Systems.
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