Claims Coding Integrity Auditor

EmblemHealth; New York (NY); Remote; USD 56,000 - 99,000; Full time

Job summary

EmblemHealth in New York seeks a Coding Integrity professional to uphold standards for claim review, policy implementation, and audit practices. You will identify inconsistencies between policies and claims and work with leadership to resolve them.

You will audit suspended and appealed claims, review medical records for accurate adjudication, and provide education on CPT, ICD-10, and HCPCS coding to internal teams and provider offices.

Qualifications

• Bachelor's degree required in healthcare/quantitative/analytical/business field
• AAPC CPC and/or CCS required
• AAPC CPMA required

Responsibilities

• Audit internal and external partners for accurate claim coding reviews pre- and post-payment.
• Audit claim reviews and medical records to ensure accurate adjudication; provide feedback to management.
• Review reporting for outlier provider claims; request records to assign diagnoses and procedures.
• Provide education on CPT, ICD-10, HCPCS coding to business and provider offices.
• Audit changes to coding from new medical policies and regulatory updates quarterly.
• Participate in RPC, RPCW, MPC and MPCW as Coding Integrity representation.
• Identify variances from industry standards and notify leadership.
• Support internal and vendor edit reviews and provider contracts.
• Perform related tasks as directed.

Skills

Coding experience

Auditing experience

MS Office proficiency

Communication skills

Prioritization

Fast-paced adaptability

Education

Bachelor's degree in healthcare/quantitative/analytical/business-related field

AAPC CPC and/or CCS

AAPC CPMA

Tools

MS Office

Job description

EmblemHealth in New York seeks a Coding Integrity professional to uphold standards for claim review, policy implementation, and audit practices. You will identify inconsistencies between policies and claims and work with leadership to resolve them.

You will audit suspended and appealed claims, review medical records for accurate adjudication, and provide education on CPT, ICD-10, and HCPCS coding to internal teams and provider offices.