Performant Healthcare, Inc.

Healthcare Services Concept Specialist (Certified Outpatient Coding SME)

Posted on

June 13, 2025

Job Type

Full-Time

Role Type

Clinical Operations

License

RN

State License

Florida

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Company Description

At Performant, we’re focused on helping our clients achieve their goals by providing technology-enabled services which identify improper payments and recoup or prevent losses due to errant billing practices. We are the premier independent healthcare payment integrity company in the US and a leader across several markets, including Medicare, Medicaid, and Commercial Healthcare. Through this important work we accomplish our mission: To offer innovative payment accuracy solutions that allow our clients to focus on what matter most – quality of care and healthier lives for all. If you are seeking an employer who values People, Innovation, Integrity, Fun, and fostering an Ownership Culture – then Performant is the place for you!

Job Description

he Healthcare Services Concept Specialist provides support to assigned Segment Specialists by maintaining current audit concepts as well as provide support for the development process of new audit concepts.

Requirements

Knowledge, Skills & Abilities Needed: Demonstrated knowledge of applicable Medicare and Commercial policy and claims process, and ability to research and analyze the same, to successfully perform the job. Relevant knowledge and experience with ICD-10-CM/PCS, CPT-4, and HCPCS coding. Knowledge of the national coding standards, particularly payment rules. Knowledge of Medicare and commercial claims processing systems. Ability to understand and apply complex policies, procedures, regulations, and legal statutes. Strong verbal communication and interpersonal skills; ability to communicate with all levels within the organization and with diverse teams. Excellent written communication skills; including proofing and editing. Good critical thinking, analytical, questioning, and listening skills; excellent attention to detail. Flexibility to handle non-standard situations as they arise; and adaptable to changing business needs in a fast-paced dynamic environment. Time management skills for managing multiple tasks simultaneously, while completing work within allocated time frames. Strong proficiency in Microsoft Word, Excel, SharePoint (advanced skills highly desirable), and easily learns and adapts to new applications and systems. Required & Preferred Qualifications: At least 2-4 years of audit or Payment Integrity experience. CPC, COC, RHIA, or RHIT certification and/or RN.

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Responsibilities

Responsible for the review and update of existing concepts based upon required periodic review cycle or as needed based upon client or regulatory changes (research, analysis, update rule documents, code lists and edits accordingly). Collaborates with and leverages Segment Specialist expertise to ensure on-point results. Ensure training material updates (may develop or coordinate) as necessary for changes to existing concepts. -May contribute to development of training materials and tools for new concepts. Conduct research, identify impact on existing concepts, and document accordingly (may support Segment specialists with research for new concepts). Interpret and apply policy in existing concept review/updates or ask may be requested in support of Segment Specialists for new concepts. Support activities required to ā€œpackageā€ concepts, including, but not limited to, pulling together necessary documents, and supporting data in appropriate order and locations, coordinating activities and documenting process steps, proofing documents, and tracking/reporting status. Ensure audit concepts are well formulated for Offerings (Data Mining vs Complex Audit vs FWA Leads & CMS vs Medicaid vs Commercial) Manage, progress, and track multiple tasks within multiple workflows for audit concept maintenance with high degree of accuracy and quality providing status reports and deliver results on-time. May contribute to responses to provider/client representative from written inquiries as it pertains to audited Medicare claims, as necessary. Stay abreast of industry policy. Works very closely with other team members to ensure on time project deliveries, cross train, and knowledge transfer, and maintain required quality and productivity standards. Performs other duties as assigned and required to meet business needs.

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