Bachelor's degree in healthcare, quantitative/analytical, or business-related field.
AAPC CPC & AAPC CIC or CCS certification required.
AAPC CPMA certification required.
4-6+ years of coding experience.
1+ year auditing experience.
Extensive knowledge of inpatient DRG clinical documentation review.
Proficiency with MS Office applications.
Responsibilities
Uphold standards for code review functions related to quality coding audit and compliance.
Identify coding compliance risks and work with leadership to resolve issues.
Audit medical records to ensure documentation supports billed conditions and DRGs.
Audit claims for accurate coding reviews across various programs.
Analyze claims by integrating coding principles and clinical guidelines.
Provide audit reporting and recommendations to management and SIU.
Prepare formal reports summarizing audit findings and recommendations.
Benefits
Professional development opportunities.
Collaborative work environment.
Access to industry-leading resources and tools.
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 business/industry/legislative issues relating to, and impacting, quality coding audit and compliance issues.
Identify inconsistencies and coding compliance risks between EH reimbursement policies and claims which directly impact claim payment (i.e. authorizations) and responsible for working with leadership to bring to resolution.
Audit inpatient and outpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed.
Principal Accountabilities
Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment.
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.
Analyze and audit claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
Identify potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
Provide audit reporting, results, and recommendations to management and SIU as appropriate.
Analyze results to assess compliance with regulations, identify procedural weaknesses and education needs that contribute to instances for non-compliance both to business, external business partners, and providers.
Prepare formal written reports summarizing current state (findings), desired future state, and critical success factors.
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.
Continuously gains knowledge of CPT, ICD, HCPCS and business/industry/legislative issues relating to and impacting Quality Coding Audit and Compliance issues.
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)
AAPC CPMA (AAPC Certified Professional Medical Auditor) (Required)
Relevant Work Experience, Knowledge, Skills, and Abilities
4 - 6+ years of coding experience. (Required)
1+ year auditing experience. (Required)
Extensive knowledge of inpatient DRG clinical documentation review. (Required)
Additional 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.
