Medical Coding (PHRN, CPC)

Cotiviti Philippines Inc; Manila; On-site; PHP 600,000 - 800,000; Full time

Job summary

Cotiviti Philippines Inc in Manila seeks a registered nurse auditor to focus on coding and clinical chart validation for outpatient and specialty audits.

The role emphasizes auditing outpatient/specialty claims, adherence to coding guidelines, medical necessity, and appropriate service settings. Requires CPC/COC/CIC/CCS certification, US healthcare experience, and strong communication with high accuracy.

Qualifications

• RN with CPC/COC/CIC/CCS certification and US healthcare auditing experience.
• Experience in coding, medical billing, and RCM operations preferred.
• Strong written and verbal communication; high accuracy.

Responsibilities

• Audits Outpatient and Specialty Claims.
• Uses client-specific guidelines to support medical audits.
• Reviews medical records and applies coding principles to identify issues.
• Maintains quality and productivity standards.

Skills

Medical coding

Auditing

Healthcare knowledge

Communication skills

Education

Registered Nurse

CPC/COC/CIC/CCS certification

Tools

Cotiviti encoder

Audit software

Job description

This auditing role will focus on Coding & Clinical Chart Validation for our Outpatient and Specialty audits. The ideal candidate for this position needs to be a registered nurse with a preferred coding / auditing background focused on one of the following disciplines from a coding and billing perspective: SNF, IRF, Home Health, APC, ER, Diagnostics and Professional Service. This position is responsible for auditing outpatient/specialty claims and documenting the results of those audits, with a focus on clinical review, coding accuracy, medical necessity, and the appropriateness of treatment setting, and services delivered.

JOB RESPONSIBILITIES:

Audits Outpatient and Specialty Claims

• Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Outpatient (APC, PNPP), Pharmacy and/or Inpatient DRG claims
• Draws on advanced coding expertise and industry knowledge to substantiate conclusions
• Respond to client logics and record reviews
• Performs work independently, reviews and interprets medical records and applies in-depth knowledge of coding principles to determine potential billing/coding issues

Effectively Utilizes Audit Tools

• Utilizes advanced proficiency, Cotiviti encoder and audit tools required to perform duties
• Enters claim into Cotiviti system accurately and in accordance with standard procedures
• Meets or Exceeds Standards/Guidelines for Productivity Maintains production goals, accuracy and quality standards set by the audit for the auditing concept

Meets or Exceeds Standards/Guidelines for Quality

• Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation
• Identifies potential claims outside of the concept where additional recoveries may be available
• Suggests and develops high quality, high value concepts and/or processes improvement, tools, etc.

Recommends New Concepts and Processes

• Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience
• Suggests, develops and implements new ideas, approaches and/or technological improvements that will support and enhance audit production, communication and client satisfaction
• Evaluates information and draws logical conclusions
• Complete all responsibilities as outlined on annual Performance Plan
• Complete all special projects and other duties as assigned
• Must be able to perform duties with or without reasonable accommodation

RELEVANT EXPERIENCE & EDUCATIONAL REQUIREMENTS:

• Registered Nurses with CPC/COC/CIC/CCS certification
• Experience in US Healthcare, medical coding, medical billing, RCM health plan operations strongly preferred
• Possesses knowledge of healthcare claims payment policy and processing – specifically CMS, Medicaid regulations, ICD-10 CM & other code sets, etc.
• Practical clinical experience working in a hospital/office strongly preferred
• Has general knowledge of medical procedures, conditions, illnesses, and treatment practices
• Possesses excellent written and verbal communication skills
• Ability to think logically and process sequentially with a high level of detailed accuracy and efficiency
• Has excellent personal computer skills in Microsoft Word, Excel, PowerPoint, Outlook, etc.