Generates comprehensive and concise in-depth reporting and analysis to track performance related to the Pre-Pay and Post-Paid Processes
Provides Provider Pre Pay production and progress reports and coordinates with management and team on recommendation for further actions and/or resolutions
Recommends process or procedure changes while building strong relationships with cross departmental teams
Demonstrates leadership ability, including mentoring Program Integrity Claims Analysts
Identifies knowledge gaps and provides training opportunities to team members
Coordinates the training of new and existing claims analyst staff
Identifies and assists in correction of organizational workflow and process inefficiencies
Serves as the primary resource for provider pre-pay team
Analyzes complex provider claims submissions using medical coding guidelines and policies
Researches, comprehends and interprets various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines

Associate’s degree or equivalent years of relevant work experience is required
Minimum of five (5) years of medical billing and coding experience
Minimum of three (3) years of SIU/FWA medical billing and coding experience
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
Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicaid/Medicare reimbursement guidelines.

PI Medical Coding Reviewer III, CPC, RHIT, RHIA required

Key skills