Program Integrity Medical Coding Reviewer III
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 include:
- Providing provider pre-pay production and progress reports and coordinating with management and team on recommendations for further actions and/or resolutions to increase team performance.
- Recommending 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.
- Demonstrating leadership ability, including mentoring Program Integrity Claims Analysts to identify and perform oversight and monitoring of claims decisions based on documentation.
- Identifying and assisting in correction of organizational workflow and process inefficiencies.
- Serving as the primary resource for provider pre-pay team.
- Using concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions.
- Researching, comprehending, and interpreting various state-specific Medicaid, federal Medicare, and ACA/Exchange laws, rules, and guidelines.
- Maintaining 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.
- Referring suspected fraud, waste, or abuse to the SIU when identified in the normal course of business.
- Responding to claim questions and concerns.
- Preparing claims for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as needed.
- Ensuring adherence to all company and departmental policies and standards for timeliness of review and release of claims.
- Building strong working relationships within all teams of Program Integrity.
- Working under limited supervision with considerable latitude for initiative and independent judgment.
- Performing any other job-related duties as requested.
We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal.com.