Program Integrity Medical Coding Reviewer III (CPC, RHIT or RHIA required)

Job Summary :

The Program Integrity Medical Coding Reviewer III generates comprehensive and concise in-depth reporting and analysis to track performance related to the Pre-Pay and Post-Paid Processes.

Essential Functions :

• Provide Provider Pre Pay production and progress reports and coordinate with management and team on recommendation for further actions and / or resolutions in order to increase team performance
• Recommend process or procedure changes while building strong relationships with cross departmental teams such as Claims, Configuration, Health Partners, and IT on identified internal system gaps
• Demonstrate leadership ability, including mentoring Program Integrity Claims Analysts to identify and perform oversight and monitoring of claims decisions based on documentation.
• Identify knowledge gaps and provide training opportunities to team members
• Coordinate the training of new and existing claims analyst staff to increase recognition of improper coding, documentation, and / or FWA
• Identify and assist in correction of organizational workflow and process inefficiencies
• Serve as the primary resource for provider pre-pay team
• Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions
• Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA / Exchange laws, rules and guidelines
• Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types along with documentation requirements
• Responsible for making claim payments decisions on a wide variety of claims including highly complicated scenarios using medical coding guidelines and policies
• Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business
• 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
• Possess a general knowledge and understanding of CareSource claim payment edits
• Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims
• Build strong working relationships within all teams of Program Integrity
• Work under limited supervision with considerable latitude for initiative and independent judgement
• Perform any other job related instructions as requested

Education and Experience :

Competencies, Knowledge and Skills :

Licensure and Certification :

Working Conditions :

Compensation Range :

$61,500.00 - $98,400.00 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 : Salary

Competencies :

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.

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