- Review and validate diagnosis and medication coding for infusion services, with a focus on payer-specific requirements and restrictions, serving as the primary resource for complex or non-standard cases.
- Analyze payer medical policies and CMS guidelines to determine coverage eligibility and medical necessity, providing expert interpretation in ambiguous or evolving policy situations.
- Ensure clinical documentation is accurately aligned with billing and coding requirements before services are rendered.
- Oversee the completion and validation of Advance Beneficiary Notices (ABNs), ensuring appropriate modifier usage and system documentation.
- Apply advanced knowledge of Medicare regulations and FDA-approved indications to support coding decisions, independently addressing exceptions, denials, and off-label coverage scenarios.
- Partner with infusion intake, billing, and clinical teams to resolve coding inconsistenc...