Program Integrity Documentation Reviewer III (CPC, RHIT or RHIA required)

Job Summary:

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 knowledge gaps and provide training opportunities to team members
• Coordinate the training of new and existing claims analyst staff to increase recognition of improper coding, documentation, and/or FWA
• 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
• Possess a general knowledge and understanding of CareSource claim payment edits
• 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
• Perform any other job related instructions as requested

Education and Experience:

• Associate’s degree or equivalent years of relevant work experience is required
• Minimum of five (5) years of medical billing and coding experience to include minimum of three (3) years of SIU/FWA medical billing and coding experience is required
• Prior experience with claim pre-payment, medical claim and documentation auditing required
• Medicaid/Medicare experience is required
• Minimum of three (3) years of experience in Facets is preferred
• Experience with reimbursement methodology (APC, DRG, OPPS) is required  
• Inpatient coding experience is preferred
• Leadership experience is preferred

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

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business