Medical Coding Reviewer III

The Program Integrity Medical Coding Reviewer III generates comprehensive and concise in-depth reporting and analysis to track performance related to the Pre-Pay and Post-Paid Processes.

Responsibilities include providing Provider Pre Pay production and progress reports, coordinating recommendations to improve team performance, recommending process changes, mentoring Program Integrity Claims Analysts, providing training, correcting workflow inefficiencies, serving as a primary resource for provider pre-pay team, analyzing provider claims submissions using CPT, ICD10, HCPCS, DRG, REV coding rules, researching relevant Medicaid, Medicare, and ACA/Exchange laws, making claim payment decisions including complex scenarios, referring suspected Fraud, Waste, or Abuse to SIU, preparing claims for Medical Director review, ensuring timely review and release of claims, and building strong team relationships.

Qualifications require an Associate's degree or equivalent experience, minimum of five years medical billing and coding experience including three years in SIU/FWA, prior claim pre-payment experience, Medicaid/Medicare experience, knowledge of reimbursement methodologies (APC, DRG, OPPS), and certification as CPC, RHIT or RHIA. Leadership experience and experience with Facets system are preferred.

Skills needed include knowledge of diagnosis codes, CPT coding guidelines, medical terminology, anatomy, medical billing processes, excellent communication, problem solving skills, and the ability to work independently and in a team. Proficiency in Microsoft Office Suite is required.

Work environment is a general office setting with possible extended periods of sitting or standing.

Compensation range is $62,700 to $100,400 annually, with additional bonus opportunities. CareSource offers a comprehensive total rewards package.