Medical Coder - Program Integrity Auditor

Transform Your Career with Evolent

At Evolent, we are on a mission to revolutionize health care by partnering with health plans and providers to enhance outcomes for individuals dealing with complex and costly health conditions. We strive to close the gaps in the healthcare system, ensuring that every individual receives the compassionate care that we would wish for our own loved ones.

We emphasize work/life balance and offer flexibility to enable our employees to adjust their work to suit their lives. We believe the best work is accomplished in an environment that promotes personal well-being and encourages authenticity. Our commitment to diversity and inclusion is fundamental to our organization.

Join us for the mission, and stay for the culture!

Key Responsibilities:

• Work closely with SIU Investigators to support research and provide informed coding decisions.
• Analyze and interpret patient medical records pertinent to FWA investigations.
• Review claims submissions to evaluate the nature and extent of billable services.
• Assess the appropriateness of billing and reimbursement procedures.
• Document claim findings in a structured format.
• Summarize claims evaluations in comprehensive reports.
• Extract and code CPT, HCPCS, Revenue Codes, DRG codes, and ICD-10 from medical records.
• Stay informed about current coding guidelines and relevant federal and state regulations.
• Conduct data analysis and support client data mining initiatives.
• Provide SIU expertise and assistance to clients when needed.
• Consistently adhere to Privacy and Security standards.
• Understand and comply with all company Privacy and Security policies.
• Carry out additional tasks as required.

Qualifications:

• Strong knowledge of anatomy, medical terminology, and billing practices.
• Thorough understanding of ICD-10-CM/PCS, HCPCS/CPT coding systems.
• Familiarity with APR-DRG, MS-DRG codes, and plan benefit designs.
• 1-2 years of experience in reviewing and auditing medical records in health plans or similar environments.
• Proficient in identifying and abstracting information from medical records to ensure compliance with coding guidelines.
• Knowledge across various specialty medical practices.
• Detail-oriented with exceptional verbal and written communication skills.
• Strong listening and interpersonal capabilities.
• Ability to work independently while displaying self-discipline.
• Aptitude for achieving defined performance and production targets.
• Proficient in MS Word, Excel, PowerPoint, and Outlook; familiarity with Electronic Medical Record systems and Encoders.
• Consistent adherence to coding quality standards and thresholds.
• Bachelor's degree is preferred.
• Knowledge of Health Insurance, Managed Care, Benefit Design, Medicaid, Medicare Advantage, and Federal Regulations.
• Hands-on experience with complex medical and billing information is a plus.

Required Certification:

• Active Certified coder (RHIA, RHIT, CPC, CPMA, CIC, COC, or CCS-P) is mandatory; ongoing maintenance of certification is essential.

To guarantee a secure hiring process, we have implemented several identity verification steps, including the submission of a government-issued photo ID. Identity verification will occur during interviews, and final interviews may require onsite attendance. All candidates must undergo a comprehensive background check, in-person I-9 verification, and may be subject to drug screening before employment. Misrepresentation will lead to immediate disqualification from consideration.

Technical Requirements:

All employees must have high-speed internet (minimum 10 Mbps) at home. For call center employees, direct connectivity to the home internet router is required. These technical requirements may change based on office location reopening plans.

Evolent is an equal opportunity employer and encourages applications from all qualified candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status. If you need reasonable accommodation to access information on this website, please reach out for further assistance.

The expected base salary for this role is $50,000, with eligibility for a bonus based on predefined performance criteria. Evolent offers a comprehensive benefits package, including health insurance benefits for qualifying employees. All compensation is based on skills and experience, which may result in variations above or below the stated salary range.

If your ideal job isn’t listed, submit your contact details and resume, and we will be in touch if a suitable position becomes available!