Medical Coder, Program Integrity
Evolent
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $50,000 per year
About the role
- The Program Integrity Coder- FWA Auditor is responsible for verifying the accuracy of itemized, complex claim review for payment, coding, and billing guidelines in accordance with the Plans’ provider agreements and the National Healthcare Billing Audit guidelines.
- Work with SIU Investigators assisting in research, discuss to make appropriate coding determinations as needed
- Analyze and interpret patient medical records (behavioral related and other specialties) pertaining to FWA investigations as needed
- Compare information submitted on the claims to determine amount and nature of billable services as needed
- Determines appropriateness of billing and reimbursement as needed
- Documents findings for each claim line in a spreadsheet as needed
- Summarize findings in a written report as needed
- Abstracts CPT, HCPCS, Revenue Codes, DRG codes, and ICD-10 from medical records as needed
- Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations as needed
- Perform data analysis and lead generation/data mining of client data as needed
- Provide Subject Matter Expertise and SIU support to clients as needed
- Comply with Privacy and Security standards
- Understands and complies with all company Privacy and Security standards
Requirements
- Knowledge of anatomy, medical terminology, and billing
- In-depth knowledge of and ability to interpret ICD-10-CM/PCS, HCPCS/CPT
- Knowledge of APR-DRG, MS-DRG codes and DRG grouping systems and Plan benefit designs
- 1-2 years’ experience reviewing and auditing medical records, working in a health plan or health insurance, or similar environment
- Ability to identify and abstract information from medical records (paper or electronic) to ensure coding guidelines are met
- Knowledge of specialty medical practices
- Must be detail oriented
- Strong computer skills: – proficient in MS Word, Excel, PowerPoint and Outlook, familiarity with Electronic Medical Record systems and Encoders
- Bachelor’s degree
- Knowledge of Health Insurance, Managed Care, Benefit Design, Medicaid, Medicare Advantage and Federal Regulations
- Active Certified coder (RHIA, RHIT, CPC, CPMA, CIC, COC or CCS-P) REQUIRED; candidate would need to maintain active certification.
Benefits
- health insurance benefits
- comprehensive benefits
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
ICD-10-CMICD-10-PCSHCPCSCPTAPR-DRGMS-DRGdata analysiscoding guidelinesbillingmedical record auditing
Soft Skills
detail orientedanalytical skillscommunicationresearchdocumentation
Certifications
RHIARHITCPCCPMACICCOCCCS-P