Program Integrity Medical Coding Reviewer II, CPC, RHIT, RHIA
CareSource
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $54,500 - $87,300 per year
About the role
- Responsible for making claim payments decisions on a wide variety of claims within department standards
- Responsible for researching, analyzing, and making payment decisions on moderately complicated claims based on medical coding guidelines and policies
- Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business
- Acts as a technical resource to new associates by reviewing claims, training staff, responding to claim questions
- Responsible for identifying and implementing process improvements and referring system enhancement ideas to manager
- Collaborates with internal departments to facilitate claim processing and to come to appropriate claim resolutions
- 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
- Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims
- Responsible for identifying systemic claim problems/concerns and reporting them to management
- Responsible for supporting provider pre-pay and post-pay teams with coding reviews and clinical documentation reviews
- Provide support for provider appeals to denied claims
Requirements
- Associate’s degree or equivalent years of relevant work experience is required
- Minimum of three (3) years of medical bill coding is required
- Medicaid/Medicare experience is preferred
- Clinical background with a firm understanding of claims payment is preferred
- Experience with reimbursement methodology (APC, DRG, OPPS) is preferred
- Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicaid/Medicare reimbursement guidelines
- Proficient in Microsoft Office Suite
- Possess a general knowledge and healthcare claim payment processing
- Knowledge of Facets Healthcare claim system configuration knowledge or experience is preferred
- Experience reviewing medical records for the purpose of determining proper medical coding
Benefits
- Health insurance
- Retirement plans
- Paid time off
- Flexible work arrangements
- Professional development opportunities
- Bonuses
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
medical bill codingreimbursement methodologydiagnosis codesCPT coding guidelinesmedical terminologyanatomy and physiologyMedicaid reimbursement guidelinesMedicare reimbursement guidelinesclaims payment processingmedical record review
Soft Skills
analytical skillscommunicationcollaborationtrainingproblem-solvingattention to detailprocess improvementtechnical resourcecustomer serviceorganizational skills
Certifications
Associate’s degree