Bachelor's degree in healthcare, business, or quantitative science (or equivalent experience)
CCS (AHIMA Certified Coding Specialist) or CPC (AAPC Certified Professional Coder) certification
Current RN or LPN license
Clinical Documentation Reviewer certification (AAPC or ADCIS)
5-8 years of relevant professional experience
5+ years of coding experience
1 year of management or leadership experience in healthcare (preferred)
Responsibilities
Direct code review functions for authorizations, claims, grievances, and new medical policies
Ensure quality and productivity of coding appeals and work queues
Develop plans for insourcing vendor coding reviews
Manage responses to audits and inquiries from external agencies
Analyze outcomes of coding changes by external vendors
Provide internal responses to complex legal and claims issues
Collaborate with clinical administration on coding implications for care management programs
Benefits
Comprehensive health insurance
Retirement savings plan
Professional development opportunities
Flexible work arrangements
Paid time off and holidays
Full Job Description
Summary of Position
Direct the standard for code review functions in the setting of authorizations, claims review, grievance and appeal, and new medical policy implementation.
Ensure the quality and productivity of appeals and work queues of coders.
Develop and design proposed coding review functions for insourcing current vendor prepay and post payment coding reviews.
Manage EmblemHealth responses to audits and inquiries by external agencies.
Support analyses for the Special Investigations Unit and Legal Department.
Principal Accountabilities
Develop and implement changes for insourcing coding reviews from vendors.
Design plans and processes to ensure clinical documentation supports coding and billing.
Develop and maintain analytics and payment integrity savings reports regarding clinical documentation reviews.
Represent departmental positions at meetings of, and correspondence with, the Reimbursement Policy Committee.
Analyze and report outcomes measures for coding changes by external vendors.
Provide the internal responses to complex problems including legal issues, special investigations, claims denials by provider groups.
Review claims, ensure accurate charge capture and review medical necessity for coders.
Develop guidelines for coding and documentation to ensure physician and hospital compliance.
Act as a clinical coding liaison between the utilization management, medical directors, and coding functions.
Serve as a resource for coding function in the Medical Utilizations Review Unit to ensure proper level of coding and payment of medical claims as a subject matter expert.
Collaborate with clinical administration on coding and reimbursement implications of care management programs.
Manage a partial caseload of claims reviews.
Ensure prompt and accurate responses to all internal partners.
Maintain productivity and quality measures for the coding review function within the department.
Demonstrate expertise in ICD-10-CM/PCS coding to act as a resource for the education of provider, nursing, and healthcare staff, as well as new employees.
Present findings to senior management and external parties.
Train staff as they enter the department in all areas of coding and analysis.
Research, review, and analyze new medical procedures, technology, equipment, and corresponding CPT/HCPCS (Healthcare Common Procedure Coding System) codes; gather input from providers; recommend coverage and reimbursement levels consistent with state and federal policies.
Qualifications
Education, Training, Licenses, Certifications
Bachelor's degree, preferably in a healthcare/business/quantitative science field of study. (Required); Additional experience/specialized training may be considered in lieu of educational requirements.
CCS (AHIMA Certified Coding Specialist or CPC (AAPC Certified Professional Coder). (Required)
Current and active RN or LPN license. (Required)
Clinical Documentation Reviewer certification (through AAPC or ADCIS. (Required)
Relevant Work Experience, Knowledge, Skills, and Abilities
5 - 8+ years of relevant, professional work experience. (Required)
5+ years of coding experience. (Required)
1 year management or leadership experience in a healthcare environment. (Preferred)
Strong analytic and organization abilities, along with effective presentation and collaboration skills. (Required)
Proficient with MS Office (Word, Excel, Access, PowerPoint, Outlook). (Required)
Ability to manage multiple priorities. (Required)
Excellent verbal and written communication and interpersonal skills. (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.
