Lead Coding Analyst (RN or LPN) - Remote

Summary of Position

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

• Ensure the quality and productivity of appeals and work queues of coders.

• Develop and design proposed coding review functions for insourcing current vendor prepay and post payment coding reviews.

• Manage EmblemHealth responses to audits and inquiries by external agencies.

• Support analyses for the Special Investigations Unit and Legal Department.

Principal Accountabilities

• Develop and implement changes for insourcing coding reviews from vendors.

• Design plans and processes to ensure clinical documentation supports coding and billing.

• Develop and maintain analytics and payment integrity savings reports regarding clinical documentation reviews.

• Represent departmental positions at meetings of, and correspondence with, the Reimbursement Policy Committee.

• Analyze and report outcomes measures for coding changes by external vendors.

• Provide the internal responses to complex problems including legal issues, special investigations, claims denials by provider groups.

• Review claims, ensure accurate charge capture and review medical necessity for coders.

• Develop guidelines for coding and documentation to ensure physician and hospital compliance.

• Act as a clinical coding liaison between the utilization management, medical directors, and coding functions.

• Serve as a resource for coding function in the Medical Utilizations Review Unit to ensure proper level of coding and payment of medical claims as a subject matter expert.

• Collaborate with clinical administration on coding and reimbursement implications of care management programs.

• Manage a partial caseload of claims reviews.

• Ensure prompt and accurate responses to all internal partners.

• Maintain productivity and quality measures for the coding review function within the department.

• Demonstrate expertise in ICD-10-CM/PCS coding to act as a resource for the education of provider, nursing, and healthcare staff, as well as new employees.

• Present findings to senior management and external parties.

• Train staff as they enter the department in all areas of coding and analysis.

• Research, review, and analyze new medical procedures, technology, equipment, and corresponding CPT/HCPCS (Healthcare Common Procedure Coding System) codes; gather input from providers; recommend coverage and reimbursement levels consistent with state and federal policies.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor's degree, preferably in a healthcare/business/quantitative science field of study. (Required); Additional experience/specialized training may be considered in lieu of educational requirements.
• CCS (AHIMA Certified Coding Specialist or CPC (AAPC Certified Professional Coder). (Required)
• Current and active RN or LPN license. (Required)
• Clinical Documentation Reviewer certification (through AAPC or ADCIS. (Required)

Relevant Work Experience, Knowledge, Skills, and Abilities

• 5 - 8+ years of relevant, professional work experience. (Required)
• 5+ years of coding experience. (Required)
• 1 year management or leadership experience in a healthcare environment. (Preferred)
• Strong analytic and organization abilities, along with effective presentation and collaboration skills. (Required)
• Proficient with MS Office (Word, Excel, Access, PowerPoint, Outlook). (Required)
• Ability to manage multiple priorities. (Required)
• Excellent verbal and written communication and interpersonal skills. (Required)

Additional Information

• Requisition ID: 1000003420
• Hiring Range: $77,760-$149,040