Vendor Medical Coding Analyst

CareSource•Dayton, OH

11d•$54,500 - $87,300•Onsite

About The Position

The Vendor Medical Coding Analyst is responsible for guiding the overall efficiency and accuracy of the vendor payment process through analyzing medical records and supplemental data to ensure diagnostic and procedural codes accurately reflect and support the visit as it relates to correct coding guidelines and medical necessity. In addition, they are responsible for leading the identification of root causes of claims issues and holding vendors and internal CareSource teams accountable in implementing process improvements.

Requirements

Bachelor's degree required
Equivalent years of relevant work experience may be accepted in lieu of required education
Three (3) years Medical billing coding experience required
Three (3) years of claims payment experience required
Certified Medical Coder (CPC, RHIT or RHIA) required

Nice To Haves

Three (3) years Managed Care experience preferred
Knowledge of diagnosis codes, and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicare/Medicaid/Commercial reimbursement guidelines
Intermediate level of Facets, Microsoft Word, Excel, PowerPoint and Access
Firm understanding of basic medical billing process
Reimbursement Methodology (APC, DRG, OPPS) preferred
Advanced communication skills
Data analysis and quality assurance skills
Ability to work independently and within a team environment
Ability to generate reports & identify trends in coding
Attention to detail
Familiarity of the healthcare field
Knowledge of Medicaid/Medicare/Commercial
Critical listening and thinking skills
Claims processing skills
Technical writing skills
Time management skills
Decision making/problem solving skills

Responsibilities

Audit and interpret medical procedures and terminology in medical documentation to conclude if appropriate medical coding was used in vendor claims data.
Utilize critical thinking skills, discretion and independent judgment to determine best course of action for each inquiry.
Identify root cause of vendor payment issues and lead solutioning sessions with vendor and internal CareSource teams.
Identify and implement process improvements based on analysis of issues and other gaps in processes.
Conduct audits of vendor medical records.
Assess and generate reports to determine claim impact to aid in resolution.
Collaborate with leadership to advocate resolving issues based on industry standard coding practices.
Act as a subject matter expert to analyze and decide the appropriate reimbursement for codes submitted on claims.
Track status and oversee the work to conclusion as it moves through vendor and internal teams.
Develop claims test case scenarios and test plans to ensure industry standard coding practices are implemented.
Conduct on-going monitoring and communications to promote and ensure adherence to established protocols and best practices.
Build and maintain cross-functional working relationships with operational departments, markets, and Quality leaders.
Maintain an understanding of Federal and State Regulatory requirements, i.e. CMS, ODJFS and MDCH.
Ability to interface with vendor and represent CareSource in a professional manner.
Assist the vendors proactively by evaluating risks and developing risk-mitigation actions.
Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, state and departmental confidentiality guidelines.
Perform any other job related duties as requested.