Remote Senior Medical Coding Auditor

EmblemHealth, Inc.; New York (NY); Remote; USD 68,000 - 119,000; Full time

Job summary

EmblemHealth is seeking a Senior Coding Integrity Auditor to join our remote team. You will uphold coding review standards, identify inconsistencies between reimbursement policies and claims, and ensure documentation supports DRGs billed.

In this role you will audit internal and external provider claims, review outliers, analyze coding guidance, and report findings to management. Strong CPT/ICD/HCPCS knowledge and 4–6+ years of experience are required.

Qualifications

• Bachelor’s degree in healthcare, quantitative/analytical, or business field.
• AAPC CPC & CIC or CCS required.
• AAPC CPMA required.
• 4–6+ years of coding experience.
• 1+ year auditing experience.
• Extensive knowledge of inpatient DRG clinical documentation review.
• Proficiency with MS Office (Word, Excel, Access, PowerPoint, Outlook, Teams).
• Attention to detail and timely escalation.
• Ability to prioritize and manage multiple tasks.
• Excellent communication skills with all audiences.

Responsibilities

• Audit internal and external business partners for accurate claim coding reviews for various programs, pre- and post-payment.
• Review reporting for outlier provider claims; request patient records to assign diagnoses, treatments, and procedures for coding and payment integrity.
• Analyze and audit claims by integrating medical coding principles, clinical guidelines, and objectivity in audits.
• Identify documentation and coding errors by recognizing aberrant patterns such as readmissions and HACs.
• Provide audit reporting, results, and recommendations to management and SIU.
• Analyze results to assess regulatory compliance and identify weaknesses and education needs.
• Prepare formal written reports summarizing current and desired state and success factors.
• Perform audits of changes to coding from new policies, quarterly.
• Participate in RPC, RPCW, MPC and MPCW as Coding Integrity representative at meetings.
• Identify variances from industry standards and bring to leadership’s attention.
• Continuously gain knowledge of CPT, ICD, HCPCS and related issues.
• Perform related tasks as directed.

Skills

Coding experience

Auditing experience

Inpatient DRG knowledge

Attention to detail

Communication skills

Prioritization

Fast-paced environment

Education

Bachelor’s degree (healthcare/quantitative/business)

AAPC CPC & CIC or CCS

AAPC CPMA

Tools

MS Office

Job description

EmblemHealth is seeking a Senior Coding Integrity Auditor to join our remote team. You will uphold coding review standards, identify inconsistencies between reimbursement policies and claims, and ensure documentation supports DRGs billed.

In this role you will audit internal and external provider claims, review outliers, analyze coding guidance, and report findings to management. Strong CPT/ICD/HCPCS knowledge and 4–6+ years of experience are required.