Coding Investigator Auditor - Work From Home

HCSC•Richardson, TX

4d•Remote

About The Position

This position is responsible for performing clinical, billing, coding and lowest cost setting reviews for services pre and post payment utilizing medical, contractual, legislative, policy, and other information to validate claims submitted and billed. The individual in this role will be conducting research; preparing documentation of findings and consulting with medical directors as needed. The role requires coordination with all departments involved in each case required, such as Medical Directors, internal physicians, special investigations, customer service, pass, network management, marketing, case management, legal, and pricing. This position also performs itemized bill review for high dollar claims and reimbursements.

Requirements

Bachelor Degree; one year of business experience, law enforcement experience, or regulatory agency experience may substitute for each year of college.
Certified Coding Certification, or acquire within 24 months of hire.
3 years experience in claims processing operations and reporting systems.
2 years experience in auditing or developing computer system reports.
Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation.
Awareness of claims processes and claims processing systems.
PC proficiency to include Microsoft Word and Excel and health insurance databases.
Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings.
Organizational skills and prioritization skills.

Nice To Haves

Active coding certification, including the Certified Inpatient Coder (CIC), Certified Professional Coder (CPC), or Certified Outpatient Coder (COC) certification, offered by the AAPC.
AHIMA certifications (CCS, RHIT, RHIA).
Experience partnering with internal stakeholders, including physicians and Medical Directors.

Responsibilities

Performing clinical, billing, coding and lowest cost setting reviews for services pre and post payment.
Utilizing medical, contractual, legislative, policy, and other information to validate claims submitted and billed.
Conducting research.
Preparing documentation of findings.
Consulting with medical directors as needed.
Coordinating with all departments involved in each case required, such as Medical Directors, internal physicians, special investigations, customer service, pass, network management, marketing, case management, legal, and pricing.
Performing itemized bill review for high dollar claims and reimbursements.