Claims Auditor, Reviewer and Coder

Planned Systems International, Inc.•, Remote

About The Position

Advanced Technologies & Laboratories International, Inc. (ATL) is hiring a Claims Auditor, Reviewer and Coder. The Contractor shall provide expertise in quality assurance, claims processing, medical coding, and audit activities for the WTC Health Program. Responsibilities include supporting quality assurance and audit planning, conducting claims reviews and audits, analyzing claims data to identify trends and issues, researching federal payer coverage policies, developing and improving program policies and procedures, maintaining the health plan codebook, ensuring accurate application of medical coding standards, and recommending improvements to processes and benefit plans based on industry best practices, coding guidance, reimbursement policies, and evidence-based healthcare standards. On July 1, 2011, Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH), WTC Health Program was established as a federal health care program to provide medical monitoring and treatment for eligible members in accordance with the James Zadroga 9/11 Health and Compensation Act of 2010. On December 18, 2015, President Obama signed the James Zadroga 9/11 Health and Compensation Reauthorization Act which reauthorized the WTC Health Program for 75 years, ending in 2090.

Requirements

A minimum of 5 years’ experience working with health insurance payor claims data in a health plan or managed care setting, with experience in healthcare quality, medical coding, and claims auditing.
Demonstrated expertise is in CPT, HCPC and ICD billing codes, authorization requirements and documentation, DRG, and health care claims data analysis
Proficient in Microsoft Office Suites, including Excel, Outlook, and SharePoint

Nice To Haves

A bachelor’s or master’s degree in a health profession (HIM, MPH, MHA, RN, PA, other health profession) preferred
Registered health information administrator (RHIA), Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) certification desirable

Responsibilities

Support the development and implementation of the WTC Health Program’s Quality Assurance Plan, including the development and implementation of the WTC Health Program’s Audit Plan.
Use the WTC Health Program administrative manual, medical benefit plan resources, and other applicable Program guidance to support claims review, audit activities, prior authorization recommendations, and policy interpretation.
Serve as an expert to the Program on claims processing and formal reviews (audits); supports Program claims reviews (audits) consistent with claims audits in the health insurance industry and the policies and procedures of the WTC Health Program.
Conduct research and reviews of federal payor coverage determinations, administrative/clinical activities, for development of policies and procedures, completeness, and alignment with Program requirements.
Analyze raw claims data to independently identify issues, patterns, and trends, and make final recommendations to the WTC Health Program on appropriateness for services within treatment/benefit plans, using health insurance reimbursement, medical coding/claims knowledge and expertise.
Support management and maintenance of the Program’s health plan codebook, make recommendations for code additions, and review claims to ensure proper application of ICD, HCPCS, CPT, and DRG codes.
Remain up to date with coding conventions, evidence-based practices, and federal payer policies.
Continuously review and participate in industry changes and updates, specifically but not limited to, ICD-10-CM/OCS ad AMA CPT coding guidelines to look for, and develop ways, to evaluate, improve research strategy, processes, policies, and procedures within the WTC Health Program in accordance with the Research and Evaluation Branch’s and Quality and Evaluation Team’s functions and goals.
Interface and collaborate with clinicians, medical administrators, federal staff, contract staff, and occupational health subject matter experts to support medical management, claims review, audit activities, and prior authorization recommendations.
Connect claims quality findings to broader quality assurance, utilization review, and program evaluation objectives, including identifying issues that may affect Program operations, reporting, or policy implementation.