5+ years of staff/process management experience in healthcare or reimbursement/coding methods.
5+ years' experience in ICD-10 & CPT-4 coding with certification in AAPC or AHIMA.
In-depth knowledge of state and federal regulations and CMS reimbursement methods.
Excellent communication skills with diverse audiences.
Proficient with MS Office applications.
Responsibilities
Lead coding strategy and execution to achieve savings targets.
Develop and manage clinical coding guidelines aligned with industry standards.
Drive operational efficiency through strategic policy and coding initiatives.
Serve as the primary coding advisor to ensure compliance and consistency.
Implement and expand coding-related programs with cost-benefit analysis.
Identify and implement improvements in systems and workflows.
Monitor provider abrasion and reduce appeal rates and recovery adjustments.
Deliver standardized processes across vendors and internal teams.
Mentor team members to foster collaboration and continuous learning.
Identify new opportunities for program growth and optimization.
Benefits
Remote work flexibility.
Opportunities for professional development and training.
Collaborative work culture that encourages innovation.
Comprehensive health plan compliance and regulatory alignment.
Potential for measurable impact on healthcare cost savings.
Full Job Description
REMOTE
Summary of Position
Provide enterprise-wide strategic leadership for the Coding Integrity and Provider Reimbursement teams within the Payment Integrity organization.
Oversee departmental operations, policies, and procedures to ensure alignment with health plan standards and compliance with federal and state regulatory requirements.
Serve as the organization's lead coding resource, advising cross-functional leaders and driving performance across internal and external programs.
Principal Accountabilities
Lead coding strategy and execution to achieve gross and incremental savings targets.
Lead the development and enterprise-wide management of clinical coding guidelines, including the creation, maintenance, and alignment of policies with industry standards and regulatory requirements. Ensure a structured and compliant approach to coding integrity across all lines of business.
Drive enterprise-wide operational efficiency and cost-effectiveness by leading the full lifecycle of strategic policy and coding initiatives-from development and approval through implementation and communication. Evaluate and forecast the financial impact of coding and policy changes to deliver measurable medical cost savings.
Serve as the primary coding advisor across the enterprise, ensuring consistency and compliance.
Lead implementation and expansion of coding-related programs, including cost-benefit analysis.
Identify and implement improvements in systems, procedures, and workflows.
Monitor provider abrasion and drive reductions in appeal rates and recovery adjustments.
Deliver standardized operational processes across vendors and internal teams.
Provide mentorship and guidance to team members, fostering a culture of collaboration, innovation, and continuous learning.
Ideate and identify new opportunities for program growth and optimization.
Ensure adherence to applicable federal, state, and local regulations.
Perform other related tasks/projects as directed, requested, or required.
Qualifications
Education, Training, Licenses, Certifications
Bachelor's Degree required.
Certified Coder (ex., CPC, CIC, CIMC)
Relevant Work Experience, Knowledge, Skills, and Abilities
10 - 12+ years of relevant, professional work experience. (Required)
5+ years of staff/process management experience in health care or reimbursement/coding methods, preferably within a managed care environment. (Required)
5+ years' experience in ICD-10 & CPT-4 coding w/certification in AAPC or AHIMA for direct oversight of coding functions. (Required)
Demonstrated in-depth knowledge of state and federal regulations and CMS reimbursement methods. (Required)
Demonstrated experience in the development and delivery of employee training/development. (Required)
Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences. (Required)
Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.). (Required)
Outstanding attention to detail and organizational, quantitative, and analytical abilities. (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.
