Job Description

Job Summary:

The Program Integrity Medical Coding Reviewer II is responsible for review of vendor audit activities, pended claim work queues, medical records work queues as well as claim reviews for provider pre-payment and post-payment functions.

Essential Functions:

• Responsible for making claim payments decisions on a wide variety of claims within department standards
• Responsible for researching, analyzing, and making payment decisions on moderately complicated claims based on medical coding guidelines and policies
• Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business
• Acts as a technical resource to new associates by reviewing claims, training staff, responding to claim questions
• Responsible for identifying and implementing process improvements and referring system enhancement ideas to manager
• Collaborates with internal departments to facilitate claim processing and to come to appropriate claim resolutions
• 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
• Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims
• Responsible for identifying systemic claim problems/concerns and reporting them to management
• Responsible for supporting provider pre-pay and post-pay teams with coding reviews and clinical documentation reviews
• Provide support for provider appeals to denied claims
• 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 three (3) years of medical bill coding is required
• Medicaid/Medicare experience is preferred
• Clinical background with a firm understanding of claims payment is preferred
• Experience with reimbursement methodology (APC, DRG, OPPS) is preferred

Competencies, Knowledge and Skills:

• Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicaid/Medicare reimbursement guidelines
• Proficient in Microsoft Office Suite
• Possess a general knowledge and healthcare claim payment processing
• Knowledge of Facets
• Healthcare claim system configuration knowledge or experience is preferred
• Experience reviewing medical records for the purpose of determining proper medical coding
• 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:
$53,400.00 - $85,600.00 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:
Salary

Competencies:
- Fostering a Collaborative Workplace Culture - 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 environment of belonging that welcomes and supports individuals of all backgrounds.

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