Medical Coding Auditor

PacificSource Health Plans•Bend, OR

About The Position

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths. The Medical Coding Auditor is responsible for researching and resolving grievances and appeals within the commercial line of business, applying advanced adjudication expertise, clinical interpretation, and decision-making. This role contributes to the development and refinement of claims research policies and procedures, with a focus on process improvement. The auditor supports complex claims and workflows requiring in-depth knowledge of clinical data, billing and coding standards, system functionality, and claims procedures. Additional responsibilities include identifying potentially fraudulent claims, reviewing documentation for final determinations, and coordinating recovery efforts for erroneous payments resulting from processing errors, misrepresentative billing, fraud, or abuse.

Requirements

Minimum of 4 years of experience in Level III claims adjudication or equivalent, with demonstrated ability to apply clinical knowledge, medical terminology, and coding standards (CPT, ICD-10) to resolve complex claims, conduct audits, and support fraud and compliance investigations.
Requires high school diploma or equivalent.
Thorough understanding of PacificSource products, plan designs, provider/network relationships, health insurance terminology, and industry requirements; fundamental understanding of self-insured business is helpful; awareness of healthcare regulatory trends, including the OIG work plan and other compliance enforcement priorities; intermediate understanding of healthcare reimbursement issues related to facility, supplier, and provider contracts; understanding of audit procedures, including data collection and sampling methodologies; ability to interact appropriately with all levels of management, including physicians; excellent oral and written communication and interpersonal skills; strong analytical and mathematical skills; demonstrated organizational and research skills, including the ability to evaluate situations for appropriate resolution; ability to assess severity of issues and escalate to management or external services when necessary; ability to organize and prioritize work independently with minimal oversight; ability to read and interpret health benefit language and medical records from professional and institutional sources; ability to perform coding audits to validate correct CPT and HCPCs coding; preferred computer skills include keyboarding and 10-key proficiency, and basic proficiency in Microsoft Word and Excel.
Adaptability
Building Customer Loyalty
Building Strategic Work Relationships
Building Trust
Continuous Improvement
Contributing to Team Success
Planning and Organizing
Work Standards
Accountability
Collaboration
Communication (written/verbal)
Flexibility
Listening (active)
Organizational skills/Planning and Organization
Problem Solving
Teamwork
Stoop and bend.
Sit and/or stand for extended periods of time while performing core job functions.
Repetitive motions to include typing, sorting and filing.
Light lifting and carrying of files and business materials.
Ability to read and comprehend both written and spoken English.
Communicate clearly and effectively.

Nice To Haves

Certified Professional Coder (CPC) preferred and obtained within 1 year.

Responsibilities

Participate in the provider and member appeals process; apply advanced adjudication expertise to resolve complex claim issues.
Provide high-level guidance on claims and processes requiring in-depth research and analysis; conduct initial clinical evaluations, request and review medical records, and perform coding research using CPT, HCPC, and ICD-10 standards, including unlisted procedures and code changes.
Review claims received through the Advanced Rebill and Compliance queues; demonstrate expertise in medical documentation, billing and coding practices, compliance requirements, and claims processing guidelines.
Serve as a lead resource during system upgrades; function as the interdepartmental point of contact for testing and support, create and review documentation, and facilitate training on system changes.
Perform audits to support tracking and reporting; develop and maintain audit tracking tools to share with managers and team leads and analyze audit data to identify key issues and retraining opportunities.
Provide guidance and education to internal departments on billing and coding standards, medical record review, and claims processing guidelines, support Configuration Analysts, Provider Service Representatives, Sales Representatives, and other internal stakeholders.
Develop and maintain collaborative relationships across departments to support shared goals and initiatives.
Conduct detailed research on complex claims requiring additional review; perform clinical evaluations, medical record analysis, coding research, and system edit reviews.
Establish standards to measure progress and communicate outcomes with Claims teams and other departments, support performance tracking and continuous improvement.
Develop and manage project plans for large initiatives impacting multiple areas; ensure coordination and timely execution across teams.
Support internal and cross-departmental quality improvement initiatives; contribute to process enhancements and compliance efforts.
Document issues affecting claims processing quality and communicate concerns to team leaders and relevant departments; use established channels to escalate problems appropriately.
Conduct fraud, waste, and abuse audits in alignment with compliance and audit work plans; prepare audit reports for management and legal counsel.
Investigate and resolve billing and coding-related inquiries and complaints from members, providers, regulatory agencies, and internal teams; initiate refund requests for overpayments and provide education to providers.
Lead and participate in special projects and committees as assigned; collaborate on cross-functional tasks to support organizational goals.
Occasionally operates office equipment such as portable scanners, fax machines, and copiers as needed.
Meet department and company performance and attendance expectations.
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Interact with business leaders and users, including external partners and customers as required.
Maintain professional, service-oriented relationships.
Perform other duties as assigned.