Senior Coding Integrity Auditor - Remote

EmblemHealth, Inc.; New York (NY); A distancia; USD 68.000 - 119.000; Jornada completa

Descripción de la vacante

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.

Formación

• 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.

Responsabilidades

• 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.

Conocimientos

Coding experience

Auditing experience

Inpatient DRG knowledge

Attention to detail

Communication skills

Prioritization

Fast-paced environment

Educación

Bachelor’s degree (healthcare/quantitative/business)

AAPC CPC & CIC or CCS

AAPC CPMA

Herramientas

MS Office

Descripción del empleo

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com .

Senior Coding Integrity Auditor - Remote

• Responsible for upholding the standard for code review functions in the setting of business/industry/legislative issues relating to, and impacting, quality coding audit and compliance issues.
  
• Identify inconsistencies and coding compliance risks between EH reimbursement policies and claims which directly impact claim payment (i.e. authorizations) and responsible for working with leadership to bring to resolution.
  
• Audit inpatient and outpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed.

Principal Accountabilities

• Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment.
  
• 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.
  
• Analyze and audit claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
  
• Identify potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
• Provide audit reporting, results, and recommendations to management and SIU as appropriate.
  
• Analyze results to assess compliance with regulations, identify procedural weaknesses and education needs that contribute to instances for non-compliance both to business, external business partners, and providers.
  
• Prepare formal written reports summarizing current state (findings), desired future state, and critical success factors.
  
• 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.
  
• Identify reimbursement and coding variances from industry standards and brings to leader’s attention.
  
• Continuously gains knowledge of CPT, ICD, HCPCS and business/industry/legislative issues relating to and impacting Quality Coding Audit and Compliance issues.
  
• 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)
  
• AAPC CPC (AAPC Certified Professional Coder) & AAPC CIC (Certified Inpatient Coder)/or CCS (AHIMA Certified Coding Specialist)(Required)
  
• AAPC CPMA (AAPC Certified Professional Medical Auditor) (Required)

Relevant Work Experience, Knowledge, Skills, and Abilities

• 4 – 6+ years of coding experience. (Required)
  
• 1+ year auditing experience. (Required)
  
• Extensive knowledge of inpatient DRG clinical documentation review. (Required)
  
• Additional 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: 1000003438
• Hiring Range: $68,040-$118,800

Security Disclosure

If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.

Pay Disclosure

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.

EEOC Statement

We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.

Sponsorship Statement

At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.