Lead Coding Analyst (RN or LPN) - Remote

Group Health, Inc (Parent); New York (NY); Remote; USD 120,000 - 160,000; Full time

Job summary

Group Health, Inc (Parent) in New York seeks a senior clinical coding leader to direct coding review standards across authorizations, claims review, grievances and new medical policy implementation.

You will oversee insourcing plans, maintain analytics and ensure compliance while coordinating with Legal, Compliance and utilization management. Requires CCS/CPC, RN/LPN license, 5–8+ years coding, and leadership experience.

Qualifications

• Bachelor's degree in healthcare/business/quantitative science preferred.
• CCS or CPC certification required.
• Active RN or LPN license required.
• Clinical Documentation Reviewer certification required.

Responsibilities

• Direct coding review standards for authorizations, claims review, grievances and new policy implementation.
• Ensure quality and productivity of appeals and coder work queues.
• Develop plans to insource coding reviews from vendors.
• Manage responses to audits and inquiries by external agencies.
• Support analyses for Special Investigations Unit and Legal Department.
• Develop guidelines for coding and documentation to ensure compliance.
• Present findings to senior management and external parties.
• Train staff entering the department in coding and analysis.

Skills

Analytical skills

Organization

MS Office

Multi-tasking

Verbal communication

Written communication

Education

Bachelor's degree

CCS (AHIMA) or CPC (AAPC)

RN or LPN license

Clinical Documentation Reviewer certification

Tools

Word

Excel

Access

PowerPoint

Outlook

Job description

Summary of Position

• Direct the standard for code review functions in the setting of authorizations, claims review, grievance and appeal, and new medical policy implementation.
• Ensure the quality and productivity of appeals and work queues of coders.
• Develop and design proposed coding review functions for insourcing current vendor prepay and post payment coding reviews.
• Manage EmblemHealth responses to audits and inquiries by external agencies.
• Support analyses for the Special Investigations Unit and Legal Department.

Principal Accountabilities

• Develop and implement changes for insourcing coding reviews from vendors.
• Design plans and processes to ensure clinical documentation supports coding and billing.
• Develop and maintain analytics and payment integrity savings reports regarding clinical documentation reviews.
• Represent departmental positions at meetings of, and correspondence with, the Reimbursement Policy Committee.
• Analyze and report outcomes measures for coding changes by external vendors.
• Provide the internal responses to complex problems including legal issues, special investigations, claims denials by provider groups.
• Review claims, ensure accurate charge capture and review medical necessity for coders.
• Develop guidelines for coding and documentation to ensure physician and hospital compliance.
• Act as a clinical coding liaison between the utilization management, medical directors, and coding functions.
• Serve as a resource for coding function in the Medical Utilizations Review Unit to ensure proper level of coding and payment of medical claims as a subject matter expert.
• Collaborate with clinical administration on coding and reimbursement implications of care management programs.
• Manage a partial caseload of claims reviews.
• Ensure prompt and accurate responses to all internal partners.
• Maintain productivity and quality measures for the coding review function within the department.
• Demonstrate expertise in ICD-10-CM/PCS coding to act as a resource for the education of provider, nursing, and healthcare staff, as well as new employees.
• Present findings to senior management and external parties.
• Train staff as they enter the department in all areas of coding and analysis.
• Research, review, and analyze new medical procedures, technology, equipment, and corresponding CPT/HCPCS (Healthcare Common Procedure Coding System) codes; gather input from providers; recommend coverage and reimbursement levels consistent with state and federal policies.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor's degree, preferably in a healthcare/business/quantitative science field of study. (Required); Additional experience/specialized training may be considered in lieu of educational requirements.
• CCS (AHIMA Certified Coding Specialist or CPC (AAPC Certified Professional Coder). (Required)
• Current and active RN or LPN license. (Required)
• Clinical Documentation Reviewer certification (through AAPC or ADCIS. (Required)

Relevant Work Experience, Knowledge, Skills, and Abilities

• 5 - 8+ years of relevant, professional work experience. (Required)
• 5+ years of coding experience. (Required)
• 1 year management or leadership experience in a healthcare environment. (Preferred)
• Strong analytic and organization abilities, along with effective presentation and collaboration skills. (Required)
• Proficient with MS Office (Word, Excel, Access, PowerPoint, Outlook). (Required)
• Ability to manage multiple priorities. (Required)
• Excellent verbal and written communication and interpersonal skills. (Required)