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

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.