Job Description:
• Perform medical claim reviews for the Special Investigations Unit (SIU) to ensure compliance with coding practices
• Conduct comprehensive quality reviews of completed medical coding reviews to ensure coding logic aligns with medical record documentation
• Analyze data, documentation, and evidence to identify potential billing errors, abuse, or fraudulent activity
• Handle complex coding reviews related to legal, compliance, escalations, audits, and rework initiatives
• Prepare detailed written summaries of findings and clearly articulate conclusions to leadership
• Independently research and apply state, CMS, and payer specific guidelines relevant to audits and reviews
• Identify opportunities for process improvements, cost savings, and cases that may warrant prepayment review
• Maintain accurate documentation, records, files, and tracking logs while meeting established deadlines and performance metrics
• Regularly use departmental tools and workflows with minimal assistance to support daily operations
• Provide mentorship and training to coders, offering guidance on coding quality, documentation standards, and review methodology
• Serve as management back up and support team operations in the manager’s absence.
Requirements:
• AAPC CPC certification
• 1+ year of reviewing coding consultant decisions for quality purposes
• 1+ year of developing and implementing quality remediation plans
• 1+ year of experience in medical coding in a Fraud, Waste, Abuse and/or error department
• Strong knowledge of standard industry coding guides and guidelines including CPT, HCPCS, ICD-10
• Experience with researching coding and policies.
• Experience with Microsoft products; Excel and Word
• Strong attention to detail and ability to review and interpret data.
• Demonstrates strong communication skills.
Benefits:
• medical, dental, and vision coverage
• paid time off
• retirement savings options
• wellness programs
• bonus eligibility