|Required Certifications:||CPC,CCS,RHIT,or CPMA
|Required Experience:||1 to 2 years
|Preferred Experience:||3 to 4 years
Position Purpose: Perform clinical/coding medical claim review to ensure compliance with coding practices through a comprehensive review and analysis of medical claims, medical records, claims history, state regulations, contractual obligations, corporate policies and procedures and guidelines established by the American Medical Association and the Centers for Medicare and Medicaid Services.
- Analyze provider billing practices by utilizing code auditing software, provider documentation, administrative policies, regulatory codes, legislative directives, precedent, AMA and CMS code edit criterion.
- Review medical records to ensure billing is consistent with medical record for appeals, adjustments and miscellaneous/unlisted code review.
- Review cases with Medical Director to validate decisions and identify opportunities to create medical policy in the absence of guidelines
- Assist with research of health plan coding questions.
- Identify potential billing errors, abuse, and fraud.
- Identify opportunities to flag potential cases which may warrant a prepayment review (versus an automatic system denial or payment).
- Maintain appropriate records, files, documentation, etc
- Associate’s degree in related field or equivalent experience.
- Coding certification and 2+ years of experience in medical billing & coding, coding/data analysis, accounting/business or physician/hospital data management
- RN/LPN and 2+ years of related clinical experience. Experience in provider communication and education preferred.
License/Certification: LPN, RN, CPC, CPC-H, CPC-P, CPC-A, CCS, CCS-P, RHIT, RHIA, or CPMA