Payment Integrity Coding Coordinator - Hybrid

The Coding Coordinator is responsible for performing audit activities in the areas of data mining, contract compliance, itemized bill reviews and provider outreach/education for all claim types to validate correct claims coding and billing practices. This role includes the identification and correction of abusive and wasteful billing and coding practices by conducting pre and post-payment coding compliance audits, communicating recommended solutions, and facilitating corrections, recovery of overpayments and provide education to promote correct, accurate and consistent coding and billing practices among providers.

REQUIRED QUALIFICATIONS

Required Work Experience

• 2 years of experience of professional/physician, inpatient, diagnostic and procedural coding, claims administration, claims auditing or related experience required (All Levels)

Required Education

• High-School Diploma or GED in general field of study (All Levels)

Required Licenses

• N/A

Required Certifications

• Certified Professional Coder (, CPC), or Certified Inpatient Coder (CIC)
  

PREFERRED QUALIFICATIONS

Preferred Work Experience

• 4 years of experience of medical coding, claims administration, claims auditing or related experience required (All Levels)
• 2 years of relevant hospital inpatient coding experience including DRG assignment
• Experience with coding of all claim types (All Levels)

Preferred Education

• Associate or bachelor's Degree in any general field of study. (All Levels)

Preferred Licenses

• N/A

Preferred Certifications

• Certified Professional Coder ( CPC), Certified Inpatient Coder (CIC) (All Levels)

LEVEL 1

• Through data analysis, identify areas of high risk for coding and billing variances.
• Collaborate with analyst to define reporting criteria to evaluate shifts in utilization and provider coding patterns.
• Interprets data, draws conclusions, and reviews findings with all levels within the organization
• Conducts audits of claims by selecting claims that have been identified as in scope for audit. Audits claims, medical records and corresponding documentation for appropriate coding. Applies knowledge of medical coding, diagnostic-related group (DRG) and current coding guidelines.
• Performs hospital charge audits and itemized bill audits on all high dollar claims and as needed on other questionable charges applicable to outpatient/professional services.
• Makes complex coding determinations and uses concise reasoning citing the principles and rational used in making the determination.
• Prepares results/recommendations of the coding audit findings to the providers via claims adjustment notification letters and / or other direct communication. Articulates clear and concise recommendations that may be challenged by health care providers.
• Facilitates recovery efforts of claims that were identified as incorrectly billed.
• Participate on task teams and corporate committees as required, applying coding and analytical skills
• Quantifies the financial impact for the company and reports findings to management.
• Acts as resource person for internal and external customers regarding coding and billing practices.
• Develop, maintain and follow detailed procedures on the process and business rules around audits.
• Manages ongoing audits and meets timeliness expectations.
• Develops and maintains collaborative internal relationships.
• Attend pertinent coding seminars and training, and use other resources as applicable, to maintain current knowledge of rapidly changing coding guidelines.

LEVEL 2

• Proactively review and identify potential areas of high risk for coding and billing variances.
• Develop and maintain a thorough understanding of medical coverage and reimbursement guidelines and make independent decisions.
• Facilitates meetings to discuss areas of difficulty and variance by researching recognized national coding guidelines and medical data to encourage uniformity and consistency of coding practices among providers.
• Participate on task teams and corporate committees as required, applying coding and analytical skills
• Develop clear and concise recommendations for any potential coding or reimbursement changes including full rationalization and how it might interact with current processes and policies. Present recommendations to the appropriate audience for review and approval.
• Work closely with other areas of the company to ensure implementation and updates to methodologies are made timely and accurately.
• Share knowledge of skills, projects, and business needs with peers and less experienced analysts. Trains new employees as needed

LEAD

• Plan and lead multiple projects and cross-functional teams from inception to completion. This includes working independently on creating timelines, working with other areas to define deliverables, monitoring progress, implementing the project and resolving/monitoring pre/post-implementation issues.
• Lead and/or participate on task teams and corporate committees as required, applying analytical skills and actively participating in a team environment to complete projects and accomplish goals.
• .
• Demonstrate a strong business perspective, industry-knowledge, organizational skills and communication skills. Work with and present to all levels of management, including Executives.
• Independently manage and improve organizational processes. Evaluate and create new ways to do things while making sure to incorporate input from all key stakeholders. Keeps abreast of trends or technology that could improve work flow.
• Demonstrate complete ownership and accountability in all leadership roles, process improvements and recommendations.
• Identify and explore opportunities for medical and reimbursement policy changes that support claim savings goals, while maintaining focus on appropriate reimbursement levels and relativities.
• Perform independent research to identify coding and system issues that impact medical coverage guidelines and pricing, presenting recommendations for appropriate corrective measures to management following thorough analysis & independent decision, while actively participating in the resolution.
• Act as a liaison with health services, other divisions, external vendors and analysts to assure adequate communication and coordination of audit activities, medical and reimbursement policy and coding changes.
• Support and train other employees in lower levels. Help direct a thorough and efficient review of all audit work being produced in the area.

ALL LEVELS

• Reports to a supervisor or manager who provides minimal supervision/project management. Develop own work-plans, and discusses timelines, prioritization, and objectives with supervisor or manager.
• Each progressive level includes the ability to perform the essential functions of any lower levels and mentor employees in those levels.
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Perform all other duties as assigned.