Bachelor's degree in healthcare, quantitative/analytical, or business-related field (or equivalent experience)
AAPC CPC or CCS certification required
AAPC CPMA certification required
3-5+ years of coding experience
1+ year auditing experience
Proficiency in MS Office Suite
Strong attention to detail and communication skills
Responsibilities
Uphold standards for code review in claims, grievances, and medical policy implementation
Identify and resolve inconsistencies in reimbursement policies affecting claims
Audit suspended and appealed claims for accuracy
Review coding practices of outlier providers
Educate business and provider offices on correct coding practices
Audit changes in coding due to new policies and regulations quarterly
Participate in coding integrity meetings to ensure accurate reimbursement
Benefits
Professional development opportunities
Collaborative work environment
Access to industry-leading tools and resources
Flexible work arrangements
Health and wellness programs
Full Job Description
Summary of Position
Responsible for upholding the standard for code review functions in the setting of claims review, grievance and appeal, and new medical policy implementation.
Identify inconsistencies between CCI & EH reimbursement policies and claim which directly impact claim payment (i.e. authorizations) and responsible for working with leadership to bring to resolution.
Perform audit of suspended and appealed claims reviewed by coding staff.
Perform audits of outlier providers for accurate coding practices and documentation requirements.
Principal Accountabilities
Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment.
Audit claim reviews and medical records to ensure accurate adjudication; review decisions from Coding Integrity team; provide feedback, results, and recommendations to management.
Review reporting for outlier provider claims; request patient medical records to assign diagnoses, treatments, and surgical and non-surgical procedures for facility and medical services for coding and payment integrity.
Provide direct education to the business and provider offices as needed to facilitate an understanding of correct claim coding, use of CPT, ICD-10, HCPCS, etc.
Perform audits of changes to coding introduced by new medical policies, reimbursement policies, regulatory changes, and business requirements on a quarterly basis.
Participate in RPC, RPCW, Medical Policy Committee (MPC) and Medical Policy Committee Workgroup (MPCW) as added Coding Integrity representation at meetings; ensure that decisions are appropriate and will result in accurate claim reimbursement.
Identify reimbursement and coding variances from industry standards and brings to leader's attention.
Provide support for internal and vendor edit reviews and provider contracts.
Perform related tasks as directed or required.
Qualifications
Education, Training, Licenses, Certifications
Bachelor's degree, preferably in a healthcare, quantitative/analytical, or business-related field of study. (Required); additional years of related work experience/specialized training may be considered in lieu of educational requirements.
AAPC CPMA (AAPC Certified Professional Medical Auditor) (Required)
Relevant Work Experience, Knowledge, Skills, and Abilities
3 - 5+ years of coding experience. (Required)
1+ year auditing experience. (Required)
Additional years of related work experience/specialized training may be considered in lieu of educational requirements. (Required)
Proficiency with MS Office (Word, Excel, Access, PowerPoint, Outlook, Teams, etc.) (Required)
Attention to detail; and ability to communicate or escalate issues in a timely manner. (Required)
Ability to independently prioritize and complete multiple tasks with competing priority levels and deadlines. (Required)
Ability to perform effectively in a fast-paced work environment. (Required)
Excellent communication skills (verbal, written, presentation, interpersonal) with all types and levels of audiences. (Required)
About EmblemHealth
EmblemHealth is a non-profit health insurance company based in New York City. It is one of the largest non-profit health insurers in the United States, serving over 3 million people. EmblemHealth offers a range of health insurance plans, including HMO, PPO, and EPO plans, as well as Medicare and Medicaid plans. The company also offers wellness programs and disease management services. EmblemHealth was formed in 2006 through the merger of Group Health Incorporated (GHI) and the Health Insurance Plan of Greater New York (HIP). The company has offices in New York City and Albany, New York.
