Coding Integrity Specialist
About The Position
The Coding Integrity Specialist will be responsible for reviewing coding claim edits, including CCI edits, medical necessity, diagnosis codes, and Medically Unlikely Edits (MUEs). This role involves trending claim edit errors, maintaining data for coder education, and compiling a Denials Management Report to identify and address preventable denials. The specialist will also build and maintain a shared folder of payer policies and assist in creating reference manuals for various coding specifics to ensure consistency. While certification is not initially required, the candidate is encouraged to pursue it as the role evolves. The position also involves daily patient contact and requires the ability to handle information with confidentiality and cooperate with risk, quality, and safety management activities.
Requirements
- High School Diploma
- Billing & Coding knowledge preferred
- Person is encouraged to become a certified coder as claim edits become less, denials become less, pending clinic accounts become less and this position only maintains payer policy manual and reference manual they would be able to fill in for any attrition and/or be back up for PTO or as services grow.
Nice To Haves
- Person hired would not have to be a certified coder but need billing and medical experience.
Responsibilities
- Work coding claim edits
- Review CCI edits and documentation to determine if modifiers are appropriate
- Review claims edits for medical necessity
- Review documentation for supporting diagnosis codes
- Review claim edits for MUE’s (Medically Unlikely Edits) and determine appropriate correction
- Review claim edits to determine if claim should be sent to different queue
- Trend claim edit errors
- Maintain data on edits to identify trending to be used coder education sessions as well as performance reviews
- Compile user friendly Denials Management Report from Qlik Denials Management Report to aid in determining true, preventable denials that we can put into an action plan to decrease such denials
- Build and maintain a shared folder of payer policies for coding and medical necessity to aid in decreasing claim edits and denials based on these policies
- Help build and maintain reference manuals for ER, IC, WC, IP, OBS, clinic specifics to ensure consistency when cross-training or hiring new coders
- Any other assigned duties
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
