Program Integrity Coding & Research Analyst (Health Plan Experienced)

CareSource; United States; Teletrabalho; USD 72 000 - 116 000; Tempo integral

Resumo da oferta

CareSource is seeking a Program Integrity Coding & Research Analyst to act as the coding SME for complex provider claims and to lead audit activities within Program Integrity. The role requires deep CPT/ICD-10/HCPCS/DRG knowledge and strong analytical skills.

You will guide root cause analyses, oversee internal audits, and collaborate across departments to enhance processes, savings, and fraud risk mitigation. CPC certification and Medicaid policy experience are highly valued.

Qualificações

• Bachelor's degree in Business Administration or related field required.
• Seven (7) years of medical coding experience required, including program integrity coding.
• Five (5) years of Medicaid policy experience preferred.
• CPC certification or equivalent required.
• Experience with reimbursement methodologies (APC, DRG, OPPS) preferred.

Responsabilidades

• Act as a Medical Coding SME for complex coding concerns within Program Integrity.
• Lead root cause analysis of provider claim issues by evaluating system config, policies, and data.
• Oversee quality audit programs for internal coding validation analysts and generate monthly reports.
• Research policy impacts and communicate audit implications to the business.
• Assist in developing and implementing annual audit plans for high-risk providers.
• Serve as SME for claim accuracy audits across the audit lifecycle, including disputes.

Conhecimentos

CPT coding

ICD-10 coding

HCPCS coding

DRG

REV coding rules

Root cause analysis

Audit programs

AI auditing workflows

Microsoft Office

Communication skills

Formação académica

Bachelor's degree in Business Administration or related field

Seven (7) years of medical coding experience

Five (5) years of Medicaid policy experience

Certified Professional Coder (CPC) or equivalent

Experience with reimbursement methodologies (APC, DRG, OPPS)

Ferramentas

Microsoft Office

Descrição da oferta de emprego

Job Summary: The Program Integrity Coding & Research Analyst acts as a Medical Coding subject matter expert for complex coding concerns and serve as primary coding resource for Program Integrity (PI).

Essential Functions:

• Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions


• Take a lead role to determine root cause of provider claim issues and resolve by analyzing system configuration, payment policy, and claims data


• Oversight of quality audit programs for internal coding validation analysts and produce monthly reports for the managers


• Researchpolicy impacts and communicate those impacts based on audit type and risk to the business


• Assist in the development and implementation of an annual audit plan for providers with high risk for fraud using appropriate risk-based methodology


• Act as subject matter expert for claim accuracy audits for all steps in the audit lifecycle, including disputes


• Lead automation requirements for AI auditing workflows, including QA of policy summaries, checklists and other reference materials used in audits and investigations


• Collaborate in maintaining effective internal training processes


• Serve as primary contact for state and market escalations by providers


• Participate in the preparation of legal activities which includes discovery and trial preparation and testifying as needed


• Build strong working relationships with Markets and departments that are essential for resolving systemic issues and driving process improvements


• Provide critical research and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements


• Recognize inconsistencies and gaps in audit capabilities and processes and work collaboratively to resolve the identified issues


• Identify, document, and report on issues with claims reimbursement methodologies


• Support the entry and tracking of system change requests, via appropriate ticketing system, for configuration or other Program and Payment Integrity improvements, act as primary resource and SME in corporate meetings and projects


• Analyze and report measurable changes in efficiency or financial savings related to process improvements


• Perform any other job related duties as requested

Education and Experience:

• Bachelor's degree in Business Administration or related field required


• Equivalent years of relevant work experience may be accepted in lieu of required education


• Seven (7) years of experience in medical coding, to include experience in program integrity coding audit required


• Five (5) years of experience working with Medicaid policy in developing, analyzing and consulting preferred


• Experience using AI tools and processes preferred


• Experience with reimbursement methodology (APC, DRG, OPPS) required

Competencies, Knowledge and Skills:

• Proficient in Microsoft Office toolset


• Proven ability to establish effective working relationships with stakeholders at all different levels


• Excellent written and verbal communication skills


• Effective identification of business problems, assessment of proposed solutions to those problems, and understanding of the needs of stakeholders


• Ability to work independently and within a team environment


• Ability to multi-task and prioritize work to meet project deadlines


• Effective listening and critical thinking skills


• Flexibility during organizational and/or business changes


• Strong interpersonal and relationship building skills


• Effective problem-solving skills with attention to detail


• Ability to effectively and efficiently lead and/or work within a project team


• Time management skills


• Customer service oriented


• Decision making/problem solving skills


• Ability to develop, prioritize and accomplish goals


• Ability to coordinate and lead cross-functional teams

Licensure and Certification:

• Certified Professional Coder (CPC) or equivalent billing/coding designation required

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time

Travel is not typically required

Compensation Range:

$72,200.00 - $115,500.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary): Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture


• Cultivate Partnerships


• Develop Self and Others


• Drive Execution


• Influence Others


• Pursue Personal Excellence


• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time.

CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

#LI-SD1 Brand=CareSource

The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.