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Manager, Medical Coding Compliance Job in Berkeley, California

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Job Title: Manager, Medical Coding Compliance

Skills:Coding,Billing,Auditing,Management,Critical Thinking,Communication
Specialties:Multiple specialties- Professional Fee Coding and billing- knowledge of facility billing desired, but not required
Required Certifications:CPC
Preferred Certifications:CIRCC,CHC,CPC
Required Experience:5 to 7 years
Preferred Experience:8 to 10 years
Location:1608 4th Street Berkeley 94710, CA, US
Date Posted:12/3/2018

Job purpose

Cogitativo Manager of Coding Compliance will advocate and support our team in providing data-fueled solutions that help our clients improve the U.S. healthcare system. We expect the Manager of Coding Compliance position to have significant experience with coding, posting of physician and ancillary charges, charge capture, managed care claims payment techniques, provider reimbursement mechanisms. The Manager will assist in researching coding, billing guidelines and creation of documentation for Cogitativo’s payment anomaly models.


Duties and responsibilities



Primary job duties and responsibilities include:


  • In coordination with our data science teams, assist in designing and deployment of continuous improvement programs for Cogitativo’s payment integrity service offering.

·         Assist in the development and validation of the Claims Payment Integrity machine learning models. These advanced computational models are responsible for the identification of claims payment anomalies, resulting from aberrant provider billing practices, coding errors, contract misinterpretations, and internal processing payment errors.  The Manager will ensure all machine learning models are compliant with legal and statutory requirements, including Office of Insurance Regulation (OIR), Federal Employee Program (FEP), Medicare, and Medicaid.  

·         Develop and maintain a strong professional relationship with key stakeholders and internal data science teams to ensure specific and appropriate program consistency across lines of responsibility through the organization.

  • Assist with creation of presentation of payment integrity information as requested.
  • Participate in brainstorming sessions, finalization, and creation of presentation of client-specific solution recommendations.

·         Audit medical record documentation to identify incorrect coded and billed services, procedures, valid ICD-10-CM, HCPCS and CPT-4 codes (includes E/M) and modifiers



·         Minimum five years experience in the areas of Payment Integrity, claims processing, provider audit is required

·         Bachelor’s degree in a health related field or quantitative discipline is desired

·         Certification of coding expertise by either the American Academy of Professional Coders or American Health Information Management Association.

·         Extensive knowledge of medical claim edits (NCCI, LCD, et al.) is required

·         Hands-on knowledge of physician and hospital reimbursement methodologies including Medicare, Medicaid, and commercial coding practices is required

·         Strength in communication: verbal, written, and interpersonal

·         Self-motivated, exceptional organization skills and attention to detail


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