Medical Coder

Position Summary:

Perform clinical/coding medical claim review to ensure compliance with coding practices through a comprehensive review and analysis of medical claims, medical records, claims history, state regulations, contractual obligations, corporate policies and procedures and guidelines established by the American Medical Association and the Centers for Medicare and Medicaid Services.

Background & Context:

The team supports quality and compliance through correct coding and policy adherence claim and medical record reviews. The Organization's team is supportive and helpful individuals that like to have a little fun; the work environment is remote however the team uses Teams applications to access job aids and communicate with one another. There is a Teams water cooler chat where you can connect with workers that are on break. The Organization drives and is driven by its Culture values and behaviors as a way it does business with each other and for its customers.

Key Responsibilities:

* Analyze provider billing practices by utilizing code auditing software, provider documentation, administrative policies, regulatory codes, legislative directives, precedent, AMA and CMS code edit criterion

* Review medical records to ensure billing is consistent with medical record for appeals, adjustments and miscellaneous/unlisted code review

* Review cases with Medical Director to validate decisions and identify opportunities to create medical policy in the absence of guidelines

* Assist with research of health plan coding questions

* Identify potential billing errors, abuse, and fraud

* Identify opportunities to flag potential cases which may warrant a prepayment review (versus an automatic system denial or payment)

* Maintain appropriate records, files, documentation, etc

* Performs other duties as assigned

* Complies with all policies and standards

Qualification & Experience:

* Associate's degree in related field or equivalent experience. Coding certification and 2+ years of experience in medical billing & coding, coding/data analysis, accounting/business or physician/hospital data management or RN/LPN and 2+ years of related clinical experience. Experience in provider communication and education preferred.

* LPN, RN, CPC, CPC-H, CPC-P, CPC-A, CCS, CCS-P, RHIT, RHIA, CPMA, or Paramedic