Vendor Medical Coding Analyst

Role Overview

• Analyze medical records and supplemental data to ensure diagnostic and procedural codes accurately reflect and support the visit as it relates to correct coding guidelines and medical necessity
• Lead the identification of root causes of claims issues
• Hold vendors and internal CareSource teams accountable in implementing process improvements
• Audit and interpret medical procedures and terminology in medical documentation
• Utilize critical thinking skills, discretion and independent judgment to determine best course of action for each inquiry
• Identify root cause of vendor payment issues
• Lead solutioning sessions with vendor and internal CareSource teams
• Conduct audits of vendor medical records
• Assess and generate reports to determine claim impact to aid in resolution
• Collaborate with leadership to advocate resolving issues based on industry standard coding practices
• Act as a subject matter expert to analyze and decide the appropriate reimbursement for codes submitted on claims
• Track status and oversee the work to conclusion as it moves through vendor and internal teams
• Develop claims test case scenarios and test plans to ensure industry standard coding practices are implemented
• Conduct on-going monitoring and communications to promote and ensure adherence to established protocols and best practices
• Build and maintain cross-functional working relationships with operational departments, markets, and Quality leaders
• Maintain an understanding of Federal and State Regulatory requirements
• Interface with vendor and represent CareSource in a professional manner
• Assist the vendors proactively by evaluating risks and developing risk-mitigation actions

Requirements

• Bachelor's degree required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Three (3) years Medical billing coding experience required
• Three (3) years Managed Care experience preferred
• Three (3) years of claims payment experience required
• Knowledge of diagnosis codes, and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicare/Medicaid/Commercial reimbursement guidelines
• Intermediate level of Facets, Microsoft Word, Excel, PowerPoint and Access
• Firm understanding of basic medical billing process
• Reimbursement Methodology (APC, DRG, OPPS) preferred
• Advanced communication skills
• Data analysis and quality assurance skills
• Ability to work independently and within a team environment
• Ability to generate reports & identify trends in coding
• Attention to detail
• Familiarity of the healthcare field
• Knowledge of Medicaid/Medicare/Commercial
• Critical listening and thinking skills
• Claims processing skills
• Technical writing skills
• Time management skills
• Decision making/problem solving skills
• Certified Medical Coder (CPC, RHIT or RHIA) required

Benefits

• bonuses tied to company and individual performance
• comprehensive total rewards package