Senior Coding Integrity Auditor - Remote

EmblemHealth; New York (NY); À distance; USD 68 000 - 119 000; Plein temps

Résumé du poste

EmblemHealth is seeking a Coding Integrity Auditor to uphold coding review standards in relation to reimbursement policies and compliance. You will audit inpatient and outpatient records to ensure documentation supports CPT, ICD, and DRG payments, and work with leadership to resolve inconsistencies impacting claim payment.

Responsibilities include auditing processes for pre- and post-payment, reviewing reports, and providing actionable recommendations to management.

Qualifications

• Bachelor's degree in healthcare, quantitative/analytical, or business-related field required.
• AAPC CPC & CIC/CCS or CCS certification required.
• AAPC CPMA certification required.

Responsabilités

• Audit claims for coding reviews pre- and post-payment.
• Review outlier provider claims and request records for diagnoses and procedures.
• Analyze and audit claims using coding principles and clinical guidelines.
• Identify documentation and coding errors from aberrant patterns.
• Provide audit reports and recommendations to management.

Connaissances

Attention to detail

Verbal & written communication

MS Office

Time management

Multitasking

Prioritization

Communication skills

Formation

Bachelor's degree

AAPC CPC & CIC/CCS

AAPC CPMA

Outils

MS Office Suite

Description du poste

Summary of Position

• 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.
• claim reimbursement.
• 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 elevate 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