Program Integrity Medical Coding Reviewer III (CPC, RHIT or RHIA required)

CareSource•Dayton, OH

About The Position

The Program Integrity Medical Coding Reviewer III generates comprehensive and concise in-depth reporting and analysis to track performance related to the Pre-Pay and Post-Paid Processes. Essential Functions: Provide Provider Pre Pay production and progress reports and coordinate with management and team on recommendation for further actions and/or resolutions in order to increase team performance Recommend process or procedure changes while building strong relationships with cross departmental teams such as Claims, Configuration, Health Partners, and IT on identified internal system gaps Demonstrate leadership ability, including mentoring Program Integrity Claims Analysts to identify and perform oversight and monitoring of claims decisions based on documentation. Identify knowledge gaps and provide training opportunities to team members Coordinate the training of new and existing claims analyst staff to increase recognition of improper coding, documentation, and/or FWA Identify and assist in correction of organizational workflow and process inefficiencies Serve as the primary resource for provider pre-pay team Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types along with documentation requirements Responsible for making claim payments decisions on a wide variety of claims including highly complicated scenarios using medical coding guidelines and policies Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business Responds to claim questions and concerns Prepares claims for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as needed Possess a general knowledge and understanding of CareSource claim payment edits Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims Build strong working relationships within all teams of Program Integrity Work under limited supervision with considerable latitude for initiative and independent judgement Perform any other job related instructions as requested

Requirements

Associate’s degree or equivalent years of relevant work experience is required
Minimum of five (5) years of medical billing and coding experience to include minimum of three (3) years of SIU/FWA medical billing and coding experience is required
Prior experience with claim pre-payment, medical claim and documentation auditing required
Medicaid/Medicare experience is required
Experience with reimbursement methodology (APC, DRG, OPPS) is required
Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicaid/Medicare reimbursement guidelines
Thorough understanding of medical claim configuration
Clinical or medical coding background with a firm understanding of claims payment
Proficient in Microsoft Office Suite
Firm understanding of basic medical billing process
Excellent written and verbal communication skills
Ability to work independently and within a team environment
Effective problem solving skills with attention to detail
Knowledge of Medicaid/Medicare and familiarity of healthcare industry
Effective listening and critical thinking skills
Ability to develop, prioritize and accomplish goals
Strong interpersonal skills and high level of professionalism
Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hire

Nice To Haves

Minimum of three (3) years of experience in Facets is preferred
Inpatient coding experience is preferred
Leadership experience is preferred

Responsibilities

Provide Provider Pre Pay production and progress reports and coordinate with management and team on recommendation for further actions and/or resolutions in order to increase team performance
Recommend process or procedure changes while building strong relationships with cross departmental teams such as Claims, Configuration, Health Partners, and IT on identified internal system gaps
Demonstrate leadership ability, including mentoring Program Integrity Claims Analysts to identify and perform oversight and monitoring of claims decisions based on documentation.
Identify knowledge gaps and provide training opportunities to team members
Coordinate the training of new and existing claims analyst staff to increase recognition of improper coding, documentation, and/or FWA
Identify and assist in correction of organizational workflow and process inefficiencies
Serve as the primary resource for provider pre-pay team
Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions
Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines
Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types along with documentation requirements
Responsible for making claim payments decisions on a wide variety of claims including highly complicated scenarios using medical coding guidelines and policies
Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business
Responds to claim questions and concerns
Prepares claims for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as needed
Possess a general knowledge and understanding of CareSource claim payment edits
Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims
Build strong working relationships within all teams of Program Integrity
Work under limited supervision with considerable latitude for initiative and independent judgement
Perform any other job related instructions as requested