The Program Integrity Coder
FWA Auditor is responsible for verifying the accuracy of itemized, complex claim review for payment, coding, and billing guidelines in accordance with the Plans’ provider agreements and the National Healthcare Billing Audit guidelines.
Work with SIU Investigators assisting in research, discuss to make appropriate coding determinations as needed
Analyze and interpret patient medical records (behavioral related and other specialties) pertaining to FWA investigations as needed
Compare information submitted on the claims to determine amount and nature of billable services as needed
Determines appropriateness of billing and reimbursement as needed
Documents findings for each claim line in a spreadsheet as needed
Summarize findings in a written report as needed
Abstracts CPT, HCPCS, Revenue Codes, DRG codes, and ICD-10 from medical records as needed
Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations as needed
Perform data analysis and lead generation/data mining of client data as needed
Provide Subject Matter Expertise and SIU support to clients as needed
Comply with Privacy and Security standards
Understands and complies with all company Privacy and Security standards

Knowledge of anatomy, medical terminology, and billing
In-depth knowledge of and ability to interpret ICD-10-CM/PCS, HCPCS/CPT
Knowledge of APR-DRG, MS-DRG codes and DRG grouping systems and Plan benefit designs
1-2 years’ experience reviewing and auditing medical records, working in a health plan or health insurance, or similar environment
Ability to identify and abstract information from medical records (paper or electronic) to ensure coding guidelines are met
Knowledge of specialty medical practices
Must be detail oriented
Strong computer skills: – proficient in MS Word, Excel, PowerPoint and Outlook, familiarity with Electronic Medical Record systems and Encoders
Bachelor’s degree
Knowledge of Health Insurance, Managed Care, Benefit Design, Medicaid, Medicare Advantage and Federal Regulations
Active Certified coder (RHIA, RHIT, CPC, CPMA, CIC, COC or CCS-P) REQUIRED; candidate would need to maintain active certification.

Medical Coder, Program Integrity

Key skills