Senior Clinical Coding & Reimbursement Lead

EmblemHealth; New York (NY); A distancia; USD 78.000 - 149.000; Jornada completa

Descripción de la vacante

EmblemHealth is seeking a Clinical Coding Manager to direct code review standards across authorizations, claims review, grievances and new policy implementation in a complex payer setting.

You will supervise coding quality, design insourcing plans from external vendors, and coordinate with audits, legal, and utilization management to ensure compliant, accurate billing and documentation.

Formación

• Bachelor's degree required; healthcare/business/quantitative science preferred.
• CCS (AHIMA) or CPC (AAPC) certification required.
• Current and active RN or LPN license required.
• Clinical Documentation Reviewer certification required.

Responsabilidades

• 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 with the Reimbursement Policy Committee.
• Analyze and report outcomes measures for coding changes by external vendors.
• Provide internal responses to complex problems including legal issues and special investigations.
• Review claims and ensure accurate charge capture and review medical necessity for coders.
• Develop guidelines for coding and documentation to ensure compliance.
• Act as a clinical coding liaison between utilization management and coding functions.
• Serve as a resource for coding in the Medical Utilizations Review Unit.
• Collaborate with clinical administration on coding and reimbursement in care management programs.
• Manage a partial caseload of claims reviews.
• Ensure prompt and accurate responses to internal partners.
• Maintain productivity and quality measures for the coding review function.
• Demonstrate ICD-10-CM/PCS expertise for education of staff and providers.
• Present findings to senior management and external parties.
• Train staff entering the department in coding and analysis.
• Research and analyze new procedures and CPT/HCPCS codes; gather input and recommend coverage.

Conocimientos

Coding experience

Healthcare leadership

Analytical skills

MS Office

Multitasking

Communication

Team collaboration

Interpersonal skills

Educación

Bachelor's degree

RN/LPN license

CCS or CPC certification

Clinical Documentation Reviewer certification

Herramientas

None

Descripción del empleo

EmblemHealth is seeking a Clinical Coding Manager to direct code review standards across authorizations, claims review, grievances and new policy implementation in a complex payer setting.

You will supervise coding quality, design insourcing plans from external vendors, and coordinate with audits, legal, and utilization management to ensure compliant, accurate billing and documentation.