Overview

Reviews and audits claims for billing, coding, services and other compliance or reimbursement issues. Assists with non-clinical aspects of the claims review process and acts as a coding resource. Provides training and support to Medical Care at Home Clinicians and staff to provide best practices of claims coding. Applies coding skills to various initiatives to ensure compliance in claims submissions. Works under moderate supervision.

Compensation:

$62,400.00 - $72,000.00 Annual

What We Provide 

• Attractive sign-on bonus and referral bonus opportunities
• Generous paid time off (PTO), starting at30 days of paid time offand 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do

• Reviews medical claims, records and other requested information for billing, coding and other compliance or reimbursement related issues; makes coding and documentation recommendations for adherence to risk adjustment models.
• Reviews medical documentation to ensure all key quality metrics are noted on claim, as provided during the encounter. Performs medical chart reviews to validate codes for quality monitoring, reporting, and analysis.
• Conducts coding reviews independently on all provider documentation to assign the correct ICD-10 codes and ensure all documentation is accurate, precise, and adherent to CMS guidelines pertinent to Risk Adjustment Hierarchical Condition Category (HCC) methodology.
• Assigns appropriate ICD10-CD, HCPCS and CPT codes as well as other codes necessary to process claims based on claim information submitted.
• Utilizes administrative policies, regulatory codes, legislative directives, and guidelines to inform decisions and appropriate coding.
• Maintains coding grids for MCAH services with the assistance of management and provides guidance on use of grids.
• Works with Clinical Director in preparing internal presentations, knowledge libraries, coding guidelines, and summary reports of coding review for department infrastructure, maintains professional communication with provider engagement team by assisting with analysis, trending, and presentation of audit/review findings, outcomes, and issues.
• Engages with medical practitioners to provide feedback and educational resources on best practices for medical coding and keeps current on new coding and billing guidelines, federal and state initiatives regarding claims and trains other staff in new/changes to regulations. Communicates and follows up with a variety of internal and external sources including but not limited to providers, members, attorneys, regulatory agencies and other carriers on any claim related matters.
• Generates routine reports for managing process time frames and vendor productivity.
• Performs insurance eligibility checks and authorization prior to for care being provided. Communicates with clinicians as needed.
• Coordinates recoupment efforts with the Practice Manager and Revenue Cycle and Finance Departments that are the result of billing errors. Responds to inquiries regarding recoupment.
• Review coding disputes, which includes review of all supporting documentation. Recommend payment based on review and prepare response to appeal.
• Participates in special projects and performs other duties as assigned.

Qualifications
Licenses and Certifications:
Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) or (CRC) Certified Risk Adjustment Coder in ICD-10-CM coding required. required Active Certified Coder Certification through AHIMA or AAPC required required
Education:
Bachelor's Degree or equivalent work experience required
Work Experience:
Minimum three years of payor work experience with medical records, including ICD-10-CM or current coding system and medical record systems required Strong knowledge of claims submission procedures and systems, State, Federal and Medicare Regulations required Knowledge of medical terminology, physiology, pharmacology, and disease processes and related procedures required Working knowledge of medical terminology, provider reimbursement, ICD-10, HCPCS and CPT-4 coding required Must be PC literate and possess a strong understanding of Microsoft applications required Ability to handle multiple priorities and meet deadlines required