Coding Integrity Auditor - Remote

Summary of Position

• Responsible for upholding the standard for code review functions in the setting of claims review, grievance and appeal, and new medical policy implementation.

• Identify inconsistencies between CCI & EH reimbursement policies and claim which directly impact claim payment (i.e. authorizations) and responsible for working with leadership to bring to resolution.

• Perform audit of suspended and appealed claims reviewed by coding staff.

• Perform audits of outlier providers for accurate coding practices and documentation requirements.

Principal Accountabilities

• Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment.

• Audit claim reviews and medical records to ensure accurate adjudication; review decisions from Coding Integrity team; provide feedback, results, and recommendations to management.

• Review reporting for outlier provider claims; request patient medical records to assign diagnoses, treatments, and surgical and non-surgical procedures for facility and medical services for coding and payment integrity.

• Provide direct education to the business and provider offices as needed to facilitate an understanding of correct claim coding, use of CPT, ICD-10, HCPCS, etc.

• Perform audits of changes to coding introduced by new medical policies, reimbursement policies, regulatory changes, and business requirements on a quarterly basis.

• Participate in RPC, RPCW, Medical Policy Committee (MPC) and Medical Policy Committee Workgroup (MPCW) as added Coding Integrity representation at meetings; ensure that decisions are appropriate and will result in accurate claim reimbursement.

• Identify reimbursement and coding variances from industry standards and brings to leader's attention.

• Provide support for internal and vendor edit reviews and provider contracts.

• Perform related tasks as directed or required.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor's degree, preferably in a healthcare, quantitative/analytical, or business-related field of study. (Required); additional years of related work experience/specialized training may be considered in lieu of educational requirements.

• AAPC CPC (AAPC Certified Professional Coder) &/or CCS (AHIMA Certified Coding Specialist). (Required)

• AAPC CPMA (AAPC Certified Professional Medical Auditor) (Required)

Relevant Work Experience, Knowledge, Skills, and Abilities

• 3 - 5+ years of coding experience. (Required)

• 1+ year auditing experience. (Required)

• Additional years of related work experience/specialized training may be considered in lieu of educational requirements. (Required)

• Proficiency with MS Office (Word, Excel, Access, PowerPoint, Outlook, Teams, etc.) (Required)

• Attention to detail; and ability to communicate or escalate issues in a timely manner. (Required)

• Ability to independently prioritize and complete multiple tasks with competing priority levels and deadlines. (Required)

• Ability to perform effectively in a fast-paced work environment. (Required)

• Excellent communication skills (verbal, written, presentation, interpersonal) with all types and levels of audiences. (Required)

Additional Information

• Requisition ID: 1000003419
• Hiring Range: $56,160-$99,360