PI Medical Coding Reviewer III (CPC, RHIT/RHIA required) — Remote

Job Summary:

The Program Integrity Medical Coding Reviewer III supports most complex medical record audit programs, dispute management, escalation management and generates concise in-depth reporting and analysis to track performance related to the Pre-Pay and Post-Paid Processes.

Essential Functions:

• Provide Provider Pre Pay production and progress reports and coordinate with management and team on recommendation for further actions and/or resolutions in order to increase team performance.
• Recommend process or procedure changes while building strong relationships with cross departmental teams such as Claims, Configuration, Health Partners, and IT on identified internal system gaps.
• Demonstrate leadership ability, including mentoring Program Integrity Audit Analysts to identify and perform oversight and monitoring of audit decisions based on documentation.
• Identify knowledge gaps and provide training opportunities to team members.
• Coordinate the training of new and existing claims analyst staff to increase recognition of improper coding, documentation, and/or FWA.
• Identify and assist in correction of organizational workflow and process inefficiencies.
• Serve as a primary resource for provider escalation support, state complaints, and other inquiries.
• Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions.
• Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines.
• Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types along with documentation requirements.
• Responsible for making claim audit payments decisions on a wide variety of claims including highly complicated scenarios using medical coding guidelines and policies.
• Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business.
• Responds to internal audit inquiries, questions and concerns.
• Support quality oversight of claim audit summaries for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as needed.
• Possess a general knowledge and understanding of CareSource claim payment edits, market specific polices and contracts.
• Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims.
• Build strong working relationships within all teams of Program Integrity.
• Work under limited supervision with considerable latitude for initiative and independent judgement.
• Perform any other job related duties as requested.

Education and Experience:

• Associates degree required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Five (5) years of medical billing and coding experience to include minimum of three (3) years of SIU/FWA medical billing and coding experience required
• Prior experience with claim pre-payment, medical claim and documentation auditing required
• Medicaid/Medicare experience required
• Three (3) years of experience in Facets preferred
• Experience with reimbursement methodology (APC, DRG, OPPS) required
• Inpatient coding experience preferred
• Leadership experience preferred

Competencies, Knowledge and Skills:

• Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicaid/Medicare reimbursement guidelines
• Thorough understanding of medical claim configuration
• Clinical or medical coding background with a firm understanding of claims payment
• Proficient in Microsoft Office Suite
• Firm understanding of basic medical billing process
• Excellent written and verbal communication skills
• Ability to work independently and within a team environment
• Effective problem solving skills with attention to detail
• Knowledge of Medicaid/Medicare and familiarity of healthcare industry
• Effective listening and critical thinking skills
• Ability to develop, prioritize and accomplish goals
• Strong interpersonal skills and high level of professionalism

Licensure and Certification:

• Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hire required

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required

Compensation Range:

Compensation Type (hourly/salary):

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business

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Brand=CareSource