Medical Coder, Program Integrity Specialist

Your Future Evolves Here

Evolent is on a mission to transform healthcare for individuals with complex and costly conditions. By collaborating with health plans and providers, we aim to create a more integrated healthcare system that offers high-quality care and compassion, just as we would want for our loved ones.

We value work/life balance, offering flexible schedules that allow you to tailor your work to your life. Our commitment to diversity and inclusion ensures that you can bring your whole self to work. Join Evolent not only for the impactful mission but also for a supportive and inclusive culture.

What You'll Be Doing:

As a Program Integrity Coder and FWA Auditor, you will play a crucial role in ensuring the integrity of claims by reviewing and verifying complex claim submissions for compliance with coding standards and billing guidelines. You will foster meaningful partnerships with both internal and external stakeholders while thriving in a collaborative environment.

Responsibilities:

• Assist SIU Investigators in researching and discussing coding determinations.
• Analyze and interpret patient medical records (including behavioral health) in relation to FWA investigations.
• Compare claim submissions to verify the nature of billable services.
• Assess billing appropriateness and reimbursement accuracy.
• Document your findings for each claim line comprehensively.
• Summarize and report your findings clearly.
• Abstract and code medical records using CPT, HCPCS, Revenue Codes, DRG codes, and ICD-10.
• Stay updated with coding guidelines and relevant federal and state regulations.
• Conduct data analysis and assist in data mining of client data.
• Provide Subject Matter Expertise and SIU support to clients.
• Adhere to Privacy and Security standards and protocols.
• Perform other related duties as assigned.

Qualifications (Required & Preferred):

• Strong understanding of anatomy, medical terminology, and billing practices.
• In-depth knowledge of ICD-10-CM/PCS and HCPCS/CPT.
• Familiarity with APR-DRG, MS-DRG coding systems, and Plan benefit designs.
• 1-2 years of experience in medical record review and auditing, preferably within a health plan or insurance environment.
• Ability to extract relevant information from medical records to ensure coding compliance.
• Knowledge of specialty medical practices is beneficial.
• Meticulous attention to detail.
• Effective verbal and written communication skills.
• Excellent active listening abilities.
• Self-directed and responsible, with strong self-discipline.
• Consistent performance in meeting production and quality goals.
• Proficient in Microsoft Office Suite, with familiarity in Electronic Medical Record systems.
• Bachelor's degree is preferred.
• Understanding of Health Insurance, Managed Care, Benefit Design, and Federal Regulations is a plus.
• Experience handling complex medical and billing information is preferred.

CERTIFICATE/LICENSE (REQUIRED)

• Active Certified coder (RHIA, RHIT, CPC, CPMA, CIC, COC, or CCS-P) is REQUIRED. Candidates must maintain active certification.

To ensure a secure hiring process, candidates will undergo identity verification steps, including the submission of a government-issued photo ID. Comprehensive background checks, in-person I-9 verification, and potential drug screenings may be conducted prior to employment. The use of artificial intelligence tools during interviews is prohibited.

Technical Requirements:

All employees must have high-speed internet access of 10 Mbps or more. Call center employees must connect directly to a home internet router. These requirements may change with office reopenings.

Evolent is an equal opportunity employer and considers all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability. For reasonable accommodations regarding job information, please reach out via email.

The expected base salary for this position is $50,000, with eligibility for a performance-based bonus. Evolent offers a comprehensive benefits package, including health insurance, to qualifying employees. Compensation is based on required skills and experience, which may vary.

If you don’t find your dream job, please submit your contact information and resume, and we will reach out if we find a suitable match!