EmblemHealth · 1 month ago
Sr. Coding Integrity Auditor (Remote)
United States
Full-time
Remote
Mid, Senior Level
$68K/yr - $119K/yr
4+ years expEmblemHealth is a healthcare organization focused on ensuring quality coding audit and compliance. The Sr. Coding Integrity Auditor is responsible for auditing medical records, ensuring compliance with coding standards, and providing recommendations to management based on audit findings.
InsuranceNon ProfitWellness
Responsibilities
Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment
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
Analyze and audit claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities
Identify potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs)
Provide audit reporting, results, and recommendations to management and SIU as appropriate
Analyze results to assess compliance with regulations, identify procedural weaknesses and education needs that contribute to instances for non-compliance both to business, external business partners, and providers
Prepare formal written reports summarizing current state (findings), desired future state, and critical success factors
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
Continuously gains knowledge of CPT, ICD, HCPCS and business/industry/legislative issues relating to and impacting Quality Coding Audit and Compliance issues
Perform related tasks as directed or required
Qualification
Required
Bachelor's degree, preferably in a healthcare, quantitative/analytical, or business-related field of study
AAPC CPC (AAPC Certified Professional Coder) & AAPC CIC (Certified Inpatient Coder)/or CCS (AHIMA Certified Coding Specialist)
AAPC CPMA (AAPC Certified Professional Medical Auditor)
4 – 6+ years of coding experience
1+ year auditing experience
Extensive knowledge of inpatient DRG clinical documentation review
Additional related work experience/specialized training may be considered in lieu of educational requirements
Proficiency with MS Office (Word, Excel, Access, PowerPoint, Outlook, Teams, etc.)
Attention to detail; and ability to communicate or escalate issues in a timely manner
Ability to independently prioritize and complete multiple tasks with competing priority levels and deadlines
Ability to perform effectively in a fast-paced work environment
Excellent communication skills (verbal, written, presentation, interpersonal) with all types and levels of audiences
Company
EmblemHealth
EmblemHealth is an insurance and wellness company that offers health benefits to consumers, employers, and government purchasers.
1001-5000 employees
H1B Sponsorship
EmblemHealth has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2024 (2)
2023 (2)
2021 (2)
2020 (4)
Funding
Current Stage
Late StageLeadership Team
M
Michael Collins
Vice President CRM Applications
Recent News
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