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Job Summary:
The Program Integrity Medical Coding Reviewer II is responsible for review of medical record audit activities, dispute support as needed, medical records work queues as well as claim reviews for provider pre-payment and post-payment functions.
Essential Functions:
Responsible for making medical records audit payment decisions on a wide variety of claim complexities within department standards.
Responsible for researching, analyzing, and making audit 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.
Responsible for meeting productivity standards while maintaining quality as outlined in SOP.
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 simple escalation and provider inquiries.
Prepares claim audit summaries 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 and process issues problems/concerns and reporting them to management.
Responsible for backing up administrative duties in medical record acquisition processes.
Responsible for identification of training and quality areas to be shared with management.
Perform any other job related duties as requested.
Education and Experience:
Associates degree required
Equivalent years of relevant work experience may be accepted in lieu of required education
Three (3) years of medical bill coding required
Medicaid/Medicare experience preferred
Clinical background with a firm understanding of claims payment preferred
Experience with reimbursement methodology (APC, DRG, OPPS) preferred
Competencies, Knowledge and Skills:
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
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
Licensure and Certification: Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hire required
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Travel is not typically required
Compensation Range:
$54,500.00 - $87,300.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary Organization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
