Coding Integrity Auditor - Remote

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

Summary of Position

• Responsible for upholding the standard for code review functions in the setting of claims review, grievance and appeal, and new medical policy implementation.
• Identify inconsistencies between CCI & EH reimbursement policies and claim which directly impact claim payment (i.e. authorizations) and responsible for working with leadership to bring to resolution.
• Perform audit of suspended and appealed claims reviewed by coding staff.
• Perform audits of outlier providers for accurate coding practices and documentation requirements.

Principal Accountabilities

• Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment.
• Audit claim reviews and medical records to ensure accurate adjudication; review decisions from Coding Integrity team; provide feedback, results, and recommendations to management.
• Review reporting for outlier provider claims; request patient medical records to assign diagnoses, treatments, and surgical and non-surgical procedures for facility and medical services for coding and payment integrity.
• Provide direct education to the business and provider offices as needed to facilitate an understanding of correct claim coding, use of CPT, ICD-10, HCPCS, etc.
• Perform audits of changes to coding introduced by new medical policies, reimbursement policies, regulatory changes, and business requirements on a quarterly basis.
• Participate in RPC, RPCW, Medical Policy Committee (MPC) and Medical Policy Committee Workgroup (MPCW) as added Coding Integrity representation at meetings; ensure that decisions are appropriate and will result in accurate claim reimbursement.
• Identify reimbursement and coding variances from industry standards and brings to leader's attention.
• Provide support for internal and vendor edit reviews and provider contracts.
• Perform related tasks as directed or required.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor's degree, preferably in a healthcare, quantitative/analytical, or business-related field of study. (Required); additional years of related work experience/specialized training may be considered in lieu of educational requirements.
• AAPC CPC (AAPC Certified Professional Coder) &/or CCS (AHIMA Certified Coding Specialist). (Required)
• AAPC CPMA (AAPC Certified Professional Medical Auditor) (Required)

Relevant Work Experience, Knowledge, Skills, and Abilities

• 3 - 5+ years of coding experience. (Required)
• 1+ year auditing experience. (Required)
• Additional years of related work experience/specialized training may be considered in lieu of educational requirements. (Required)
• Proficiency with MS Office (Word, Excel, Access, PowerPoint, Outlook, Teams, etc.) (Required)
• Attention to detail; and ability to communicate or escalation issues in a timely manner. (Required)
• Ability to independently prioritize and complete multiple tasks with competing priority levels and deadlines. (Required)
• Ability to perform effectively in a fast-paced work environment. (Required)
• Excellent communication skills (verbal, written, presentation, interpersonal) with all types and levels of audiences. (Required)

Additional Information

• Requisition ID: 1000003419
• Hiring Range: $56,160-$99,360