Sr Medical Coding Specialist

Sr Medical Coding Specialist

At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our purpose is simple - we strive to bend the cost curve in healthcare for all. Our dedication to service excellence extends to all our stakeholders -- internal and external - driving us to consistently exceed expectations. We are intentionally bold, we foster innovation, we nurture accountability, we champion diversity, and empower each other to illuminate our collective potential. Be part of our amazing transformational journey as we optimize the opportunity towards becoming a leading technology, data, and innovation voice in healthcare. Onward and Upward!!!

Job Summary

The Senior Medical Coding Specialist provides analysis of the highest dollar and most complex claims by applying research, coding standards, industry knowledge and federal regulations to ensure correct billing practices. In this role, the incumbent will perform reviews to identify variations from quality billing practices and monitor bills for accuracy and compliance. This position also requires familiarity with international coding systems and healthcare billing practices to support global operations and ensure alignment with international standards.

Job Roles and Responsibilities

1. Review and analyze complex inpatient, outpatient, and practitioner billing for medical appropriateness of treatment; analyze charges of various revenue centers with consideration to patient diagnosis, procedures, age and facility type and international healthcare norms where applicable.

2. Assist management in the daily operations and processes within the department.

3. Design and participate in the clinical and coding education of coders, negotiators, and physicians, incorporating international coding systems (e.g., ICD-10-AM, OPCS-4, SNOMED CT). This includes orientation, training and mentoring of new and existing staff.

4. Facilitate daily claim completion meetings with coding operations teams, including international counterparts when applicable; discuss complex cases, provide feedback, and initiate new coding protocols.

5. Drive successful coding operations through the application of learned, certified knowledge in addition to continuous professional development and ongoing coding research.

6. Provide general support to clinical team members, serving as a resource and subject matter expert (SME).

7. Monitors turnaround times for multiple applications and provides suggestions for process efficiencies.

8. Uses independent decision making skills to review claims after business hours to meet deadlines.

9. Apply national and international coding standards and regulations to claims billed.

10. Research and review individual claims, claim trends or detailed itemized bills, operative notes and other documentation as needed.

11. Collaborate with physician and analytics teams to create, enhance or suggest new coding edits, claim factors, guidelines and other applicable reference materials.

12. Monitor, research, and summarize trends, coding practices, and regulatory changes.

13. Apply clinical judgment and high level of expertise along with analytic skills in review of the most challenging and difficult cases; including conducting additional research as needed.

14. Communicates clinical, coding and reimbursement findings to co-workers and management in a clear, organized manner.

15. Evaluate performance of both newly hired and existing staff.

16. Assist with education of staff as it relates to claims, suggest additional negotiation talking points or tools, develop instructional design, when applicable and communicate overall industry or regulatory changes which affect the department.

17. Partner with management to drive department goals and objectives.

18. Collaborate, coordinate, and communicate across disciplines and departments, and international teams.

19. Ensure compliance with HIPAA regulations and international data protection regulations (e.g., GDPR, PIPEDA).

20. Demonstrate commitment to the Company's core values.

21. Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.

22. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

Job Scope

This position works independently with minimal supervision in order to complete the outlined responsibilities. The incumbent balances several projects at a time and work is varied and complex. More complex issues are referred to higher levels. The incumbent follows established procedures and uses knowledge of the Company's general business principles, industry dynamics, market trends, and specific operational details when performing all aspects of the job.

Compensation

The salary range for this position is $ 70-90k annually. Specific offers take into account a candidate's education, experience and skills, as well as the candidate's work location and internal equity. This position is also eligible for health insurance, 401k and bonus opportunity.

Job Requirements

• Current coding certification through AHIMA or AAPC, or medical license such as RN or MD, required
• 7+ years of experience in a clinically related field including, but not limited to, coding, auditing, nursing, radiology, laboratory, pharmacy, or physician assistant roles
• Extensive knowledge of inpatient and outpatient hospital billing and claims data, including UB-04s, revenue codes, CPT, HCPCS, ICD-10, DRG, APCs, and familiarity with international equivalents such as KSA, ICD-10-AM, ACHI, and CCI
• Extensive knowledge of international medical coding and data resources such as WHO guidelines, CPT Assistant, medical association publications, and clinical research websites supporting medical coding is required
• Knowledge of payer reimbursement policies, state and federal regulations, medical necessity criteria, and applicable industry standards
• Auditing and health information management experience in a healthcare setting preferred
• Experience and proficiency using Microsoft Office Suite, including Excel, Outlook, and PowerPoint; Visio helpful; experience with international billing platforms is a plus
• Excellent written, verbal, and listening communication skills, along with strong interpersonal, organizational, time management, analytical, problem-solving, troubleshooting, and customer service skills, including cross-cultural communication
• Ability to develop educational materials and job aids pertaining to coding and claims
• Ability to work evening or weekend hours as needed to meet deadlines
• Ability to handle multiple tasks in a fast-paced environment
• Ability to meet individual and team goals, deadlines, and work standards
• Ability to apply independent judgment and determine the appropriate course of action
• Ability to read and abstract medical records
• Extensive knowledge of medical terminology, anatomy, and physiology
• Ability to lead, teach, mentor others, and facilitate a learning environment
• Individual in this position must be able to work in a standard office environment, which requires sitting and viewing monitor(s) for extended periods of time and operating standard office equipment such as a keyboard, copier, and telephone

Benefits

We realize that our employees are instrumental to our success, and we reward them accordingly with very competitive compensation and benefits packages, an incentive bonus program, as well as recognition and awards programs. Our work environment is friendly and supportive, and we offer flexible schedules whenever possible, as well as a wide range of live and web-based professional development and educational programs to prepare you for advancement opportunities.

Your benefits will include:

• Medical, dental and vision coverage with low deductible & copay
• Life insurance
• Short and long-term disability
• Paid Parental Leave
• 401(k) + match
• Employee Stock Purchase Plan
• Generous Paid Time Off accrued based on years of service
  • WA Candidates: the accrual rate is 4.61 hours every other week for the first two years of tenure before increasing with additional years of service
• 10 paid company holidays
• Tuition reimbursement
• Flexible Spending Account
• Employee Assistance Program
• Sick time benefits for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year, unless the laws of the state in which the employee is located provide for more generous sick time benefits

EEO Statement

Claritev is an Equal Opportunity Employer and complies with all applicable laws and regulations. Qualified applicants will receive consideration for employment without regard to age, race, color, religion, gender, sexual orientation, gender identity, national origin, disability or protected veteran status. If you would like more information on your EEO rights under the law, please click here.