The Medical Claims Coding Auditor is responsible for the investigation of coding issues and recommendation for correction of the issue. Responsible for reviewing and making payment determinations on provider medical claims for Claim Check and iHealth appeals. This position will conduct root cause research and detail review of provider documents, medical records and applying medical rational. Uses Correct Coding Initiatives (CCI) and National Correct Coding Initiatives (NCCI) as a guide to uphold SWHP Policies.
"The pay range for this position is $18.49 (entry-level qualifications) - $32.94 (highly experienced) The specific rate will depend upon the successful candidate’s specific qualifications and prior experience"
ESSENTIAL FUNCTIONS OF THE ROLE
- Review medical records and documentation of claims to provide rational for upholding or overturning denials.
- Partner with SWHP Medical Director to create efficient processes and resolve potential Claim Check & iHealth system edit errors.
- Research coding documentation and new releases of information to gain knowledge and remain current in compliance, billing and medical coding regulations.
- Evaluate and identify patterns of practice and aberrant behavior by medical providers.
- Proactively address trends and review with appropriate medical consultants faculty and administrative staff.
- Serves as an internal resource and subject matter professional to the Claim Operations Department.
- Performs other position appropriate duties as required in a competent, professional and courteous manner.
KEY SUCCESS FACTORS
- Medical Terminology, Anatomy and Physiology.
- Protect Data integrity and validity.
- Abide by patient confidentially (HIPAA) regulations and guidelines for accessing and disclosure of protected health information.
- Demonstrates knowledge of Correct Coding Principals of CPT, ICD-9, HCPCS, modifiers as well as UB04 Revenue Codes.
- Ability to communicate effectively.
- Ability to work autonomously and with minimal amount of supervision.
- Proficient in reading and interpreting medical records and proficient in the use of
- Microsoft Office Suite.
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
- EDUCATION - H.S. Diploma/GED Equivalent
- EXPERIENCE - 5 Years of Experience
- CERTIFICATION/LICENSE/REGISTRATION -
Certified Coding Associate (CCA), Cert Coding Specialist (CCS), Cert Coding Spec Physician Bas (CCS-P), Cert Inpatient Coder (CIC), Cert Interv Radiology CV Coder (CIRCC), Cert Outpatient Coder (COC), Cert Professional Coder (CPC), Cert Prof Coder - Apprentice (CPC-A), Cert Prof Coder Physician (CPC-P), Home Care Coding Spec-Diagn (HCS-D), Reg Health Info Administrator (RHIA), Reg Health Information Technic (RHIT): Must have one of the following coder certs from AHIMA or AAPC: CCA,CCS,CCS-P,CIC,CIRCC,COC,COC-A,CPC,CPC-A,CPC-P,HCS-D,RHIA,RHIT.