PI Medical Coding Reviewer I

Job Summary:

The Program Integrity Medical Coding Reviewer I is responsible for the medical records request and receipt processes, dispute report tracking and updates, claim reviews for provider pre-payment and post-payment functions.

Essential Functions:

• Responsible for assuring medical records requests are accurate and sent in a timely manner
• Responsible for processing incoming medical records and assigning to appropriate claims
• Responsible for requesting claim updates for prompt pay timing, payment status, and claim notes as outlined in SOP
• Responsible for monitoring dispute and appeal reports, adding relevant items to our prepay and post pay trackers, and monitoring the trackers for timeliness
• Responsible for making claim payments decisions on claims billed with uncomplicated medical codes adhering to department standards
• Responsible for researching, analyzing, and making payment decisions on claims based on medical coding guidelines and policies
• Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business
• Responsible for identifying process improvements and referring system enhancement ideas to manager
• Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims
• Responsible for reporting claim problems/concerns to management
• Perform any other job-related instructions as requested

Education and Experience:

• Associate's degree or equivalent years of relevant work experience is required
• Minimum of one (1) year of medical bill coding is preferred
• Medicaid/Medicare experience is preferred
• Experience with reimbursement methodology (APC, DRG, OPPS) is preferred

Competencies, Knowledge and Skills:

• Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicaid/Medicare reimbursement guidelines
• Proficient in Microsoft Office Suite
• Experience reviewing medical records
• Firm understanding of basic medical billing process
• General understanding of claims payment is preferred
• Healthcare claim system configuration knowledge is preferred
• Excellent written and verbal communication skills
• Ability to work independently and within a team environment
• Effective problem-solving skills with attention to detail
• Knowledge of Medicaid/Medicare and familiarity of healthcare industry
• Effective listening and critical thinking skills
• Ability to develop, prioritize and accomplish goals Strong interpersonal skills and high level of professionalism

Licensure and Certification:

• Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hire or within 18 months of hire date

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:
$46,500.00 - $74,500.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:
Salary

Competencies:
- Create an Inclusive Environment
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.

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