Summary of Position
- Responsible for upholding the standard for code review functions in the setting of claims review, grievance and appeal, and new medical policy implementation.
- Identify inconsistencies between CCI & EH reimbursement policies and claim which directly impact claim payment (i.e. authorizations) and responsible for working with leadership to bring to resolution.
- Perform audit of suspended and appealed claims reviewed by coding staff.
- Perform audits of outlier providers for accurate coding practices and documentation requirements.
Principal Accountabilities
- Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment.
- Audit claim reviews and medical records to ensure accurate adjudication; review decisions from Coding Integrity team; provide feedback, results, and recommendations to management.
- 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.
- Provide direct education to the business and provider offices as needed to facilitate an understanding of correct claim coding, use of CPT, ICD-10, HCPCS, etc.
- 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.
- Provide support for internal and vendor edit reviews and provider contracts.
- 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); additional years of related work experience/specialized training may be considered in lieu of educational requirements.
- AAPC CPC (AAPC Certified Professional Coder) &/or CCS (AHIMA Certified Coding Specialist). (Required)
- AAPC CPMA (AAPC Certified Professional Medical Auditor) (Required)
Relevant Work Experience, Knowledge, Skills, and Abilities
- 3 - 5+ years of coding experience. (Required)
- 1+ year auditing experience. (Required)
- Additional years of 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)
Additional Information
- Requisition ID: 1000003419
- Hiring Range: $56,160-$99,360
|
EmblemHealth
Oct 22, 2026