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

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
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

Program Integrity Medical Coding Reviewer II, CPC, RHIT, RHIA

About this role