Analyst, Pre-Pay Dispute Coding (Remote)

Molina Healthcare; United States; Remote; USD 60,000 - 90,000; Full time

Job summary

Molina Healthcare seeks a Provider Denial Coding Disputes Specialist to investigate and resolve denied provider claims, ensuring coding aligns with Molina guidelines and federal/state regulations. Review medical records, denial reasons, and claim history to substantiate services and determine overturn or uphold decisions.

Role includes conducting audits, documenting findings, communicating determinations to providers, and assisting in code editing for compliance.

Qualifications

• At least 2 years of experience in medical coding or billing, or equivalent combination of relevant education and experience.
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS).
• Strong attention to detail and ability to independently read and comprehend the details of medical records.
• Comfortable working in a production-centric environment with high quality standards.
• Ability to work cross-collaboratively in a highly matrixed organization.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software program(s) proficiency.

Responsibilities

• Reviews coding-related provider claims denials by examining records and guidelines to determine substantiation of services.
• Conducts independent audits of non-medical records to verify billing accuracy and overturns or upholds denials as appropriate.
• Generates and communicates determinations to providers with guideline links.
• Identifies coding errors; collaborates with internal departments to track issues and ensure code compliance.
• Completes data points in internal applications to meet auditing requirements.
• Participates in process improvements to align with coding regulations and guidelines.

Skills

Attention to detail

Strong communication skills

Independent chart review

Cross-functional collaboration

Microsoft Office proficiency

Education

CPC or CCS Certification

Tools

Microsoft Office

Job description

Provides support for provider denial coding dispute activities. Investigates and resolves disputes related to provider appeals, and ensures that claims adhere to correct billing standards and regulations.

Essential Job Duties

• Reviews coding-related provider claims denials by systematically examining medical records, denial reasons, submitted claims, and claim history, in accordance with applicable state, federal, and Molina guidelines, rules, and protocols, to determine whether the documentation substantiates the services rendered.
• Conducts independent audits of non-medical records to verify billing accuracy; makes decisions within designated authority to either overturn or uphold denials in a timely manner.
• Generates and communicates determination to the provider using appropriate letter language and provides necessary guideline links.
• Identifies, documents, and communicates any identified coding errors or inconsistencies; collaborates with appropriate internal departments to capture and track issues, and ensure precise code editing and compliance.
• Completes data points within internal applications to comply with departmental auditing requirements.
• Actively participates in the enhancement of departmental processes to maintain alignment with current coding regulations and guidelines, while also refining internal procedures.

Required Qualifications

• At least 2 years of experience in medical coding or billing, or equivalent combination of relevant education and experience.
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS).
• Strong attention to detail and ability to independently read and comprehend the details of medical records.
• Comfortable working in a production-centric environment with high quality standards.
• Ability to work cross-collaboratively in a highly matrixed organization.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software program(s) proficiency.

Molina Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.