The Program Integrity Medical Coding Reviewer III supports complex medical record audit programs, dispute management, escalation management, and reporting/analysis related to pre-pay and post-paid processes.
- Provide provider pre-pay production and progress reports and coordinate with management and team on recommendations for further actions and resolutions.
- Recommend process and procedure changes while building strong relationships with cross-functional teams such as Claims, Configuration, Health Partners, and IT.
- Mentor Program Integrity Audit Analysts and support oversight of audit decisions based on documentation.
- Identify knowledge gaps and provide training opportunities to team members.
- Coordinate training for new and existing claims analyst staff to improve recognition of improper coding, documentation, and fraud, waste, and abuse.
- Identify and help correct workflow and process inefficiencies.
- Serve as a primary resource for provider escalation support, state complaints, and other inquiries.
- Apply CPT, ICD-10, HCPCS, DRG, and revenue code rules to analyze complex provider claims submissions.
- Research and interpret state-specific Medicaid, federal Medicare, and ACA/Exchange laws, rules, and guidelines.
- Make claim audit payment decisions for a wide variety of claims, including highly complex scenarios.
- Refer suspected fraud, waste, or abuse to SIU when identified.
- Support quality oversight of claim audit summaries for Medical Director review.
- Work under limited supervision with considerable latitude for initiative and independent judgment.
Requirements & Qualifications
Qualifications
- Associate degree required; equivalent relevant experience may be accepted in lieu of education.
- Five years of medical billing and coding experience required.
- Minimum three years of SIU/FWA medical billing and coding experience required.
- Prior experience with claim pre-payment, medical claim, and documentation auditing required.
- Medicaid/Medicare experience required.
- Experience with reimbursement methodology such as APC, DRG, and OPPS required.
- Inpatient coding experience preferred.
- Leadership experience preferred.
- Certified Medical Coder credential required at time of hire; CPC, RHIT, or RHIA accepted.
Knowledge and Skills
- Knowledge of diagnosis codes, CPT coding guidelines, medical terminology, anatomy and physiology, and Medicaid/Medicare reimbursement guidelines.
- Understanding of medical claim configuration and claims payment.
- Proficiency with Microsoft Office Suite.
- Strong written and verbal communication skills.
- Ability to work independently and within a team environment.
- Strong problem-solving, critical thinking, and attention to detail.
Location
N/A
Employment Type
Full-time
Experience Level
Senior
Salary Range
$62,700 - $100,400
Remote work allowed
Yes
Posted
1 week ago
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