Remote Medical Coding Auditor

Job Description

The Program Integrity Medical Coding Reviewer III generates comprehensive and concise in-depth

reporting and analysis to track performance related to the Pre-Pay and Post-Paid Processes.

Essential Functions

• Provide Provider Pre Pay production and progress reports and coordinate with management

and team on recommendation for further actions and/or resolutions in order to increase team

performance

• Recommend process or procedure changes while building strong relationships with cross

departmental teams such as Claims, Configuration, Health Partners, and IT on identified

internal system gaps

• Demonstrate leadership ability, including mentoring Program Integrity Claims Analysts to

identify and perform oversight and monitoring of claims decisions based on documentation

• Identify and assist in correction of organizational workflow and process inefficiencies

• Serve as the primary resource for provider pre-pay team

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

complex provider claims submissions

• Research, comprehend and interpret various state specific Medicaid, federal Medicare, and

ACA/Exchange laws, rules and guidelines

• Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for

various provider specialty types along with documentation requirements

• Responsible for making claim payments decisions on a wide variety of claims including highly

complicated scenarios using medical coding guidelines and policies

• Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of

business

• Responds to claim questions and concerns

• Prepares claims for Medical Director review by completing required documentation and

ensuring all pertinent medical information is attached as needed

• Ensure adherence to all company and departmental policies and standards for timeliness of

review and release of claims

• Build strong working relationships within all teams of Program Integrity

• Work under limited supervision with considerable latitude for initiative and independent

judgement

• Performs any other job related duties as requested.

We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to View email address on click.appcast.io learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy:

Skills and Requirements

Education and Experience

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

• Five (5) years of medical billing and coding experience to include minimum of three (3) years

of SIU/FWA medical billing and coding experience required

• Prior experience with claim pre-payment, medical claim and documentation auditing required

• Medicaid/Medicare experience required

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

• Able to work off of a virtual desktop with your own laptop/equipment

• This position must be their only role within medical coding/auditing due to potential conflict of interest

Competencies, Knowledge and Skills

• Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and

physiology; and Medicaid/Medicare reimbursement guidelines

• Thorough understanding of medical claim configuration

• Clinical or medical coding background with a firm understanding of claims payment

• Proficient in Microsoft Office Suite

• Firm understanding of basic medical billing process

• Excellent written and verbal communication skills

• Ability to work independently and within a team environment

• Effective problem solving skills with attention to detail

• Knowledge of Medicaid/Medicare and familiarity of healthcare industry

• Effective listening and critical thinking skills

• Ability to develop, prioritize and accomplish goals

• Strong interpersonal skills and high level of professionalism

Licensure and Certification

• Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hire required • Inpatient coding experience preferred

• Three (3) years of experience in Facets preferred