PI Medical Coding Reviewer III (CPC, RHIT or RHIA required)

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 performanceRecommend process or procedure changes while building strong relationships with cross departmental teams such as Claims, Configuration, Health Partners, and IT on identified internal system gapsDemonstrate 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 membersCoordinate the training of new and existing claims analyst staff to increase recognition of improper coding, documentation, and/or FWAIdentify and assist in correction of organizational workflow and process inefficienciesServe as the primary resource for provider pre-pay teamUse concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissionsResearch, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelinesMaintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types along with documentation requirementsResponsible for making claim payments decisions on a wide variety of claims including highly complicated scenarios using medical coding guidelines and policiesRefer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of businessResponds to claim questions and concernsPrepares claims for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as neededPossess a general knowledge and understanding of CareSource claim payment editsEnsure adherence to all company and departmental policies and standards for timeliness of review and release of claimsBuild strong working relationships within all teams of Program IntegrityWork under limited supervision with considerable latitude for initiative and independent judgementPerform any other job related instructions as requestedEducation and Experience:Associate’s degree or equivalent years of relevant work experience is requiredMinimum 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 requiredPrior experience with claim pre-payment, medical claim and documentation auditing requiredMedicaid/Medicare experience is requiredMinimum of three (3) years of experience in Facets is preferredExperience with reimbursement methodology (APC, DRG, OPPS) is required Inpatient coding experience is preferredLeadership experience is preferredCompetencies, Knowledge and Skills:Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicaid/Medicare reimbursement guidelinesThorough understanding of medical claim configurationClinical or medical coding background with a firm understanding of claims paymentProficient in Microsoft Office SuiteFirm understanding of basic medical billing processExcellent written and verbal communication skillsAbility to work independently and within a team environmentEffective problem solving skills with attention to detailKnowledge of Medicaid/Medicare and familiarity of healthcare industryEffective listening and critical thinking skillsAbility to develop, prioritize and accomplish goalsStrong interpersonal skills and high level of professionalismLicensure and Certification:Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hireWorking Conditions:General office environment; may be required to sit or stand for extended periods of timeCompensation Range:$62,700.00 - $100,400.00CareSource 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):SalaryOrganization Level Competencies Fostering a Collaborative Workplace CultureCultivate PartnershipsDevelop Self and OthersDrive ExecutionInfluence OthersPursue Personal ExcellenceUnderstand 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.#LI-SD1