Penstock is a service partner and SaaS builder for forward-thinking health plans and providers, focusing on recovery, audit, and regulatory teams to improve accuracy and reduce wasted spend in healthcare. The Concept and Edit Analyst is a subject matter expert responsible for developing, auditing, validating, and improving concepts and edits that support claim selection for audits. This role ensures selection logic is effective, accurate, and actionable in a live environment.
Key responsibilities include:
- Participating in concept and edit development lifecycle including research, design, validation, documentation, and audit creation
- Conducting data mining and analysis to validate performance and identify trends and recovery opportunities
- Developing and auditing concept logic and code sets aligning with business rules and reimbursement methods
- Serving as a production auditor to ensure audit accuracy and quality
- Developing concepts related to payment integrity scenarios (e.g., Frequency, Unit Based Concepts)
- Researching and applying regulations, policies, contracts, and coding standards to ensure concept validity
- Analyzing results to refine concepts and improve performance
- Collaborating with IT on system changes affecting concept accuracy
- Supporting monthly claim selection and production audits
- Training audit teams on new or enhanced concepts and edits
- Creating analytical tools and reports to monitor and improve concept performance
- Staying current on coding, reimbursement, clinical and industry changes impacting concepts
- Providing expertise and guidance to teams and supporting payment integrity initiatives
Qualifications:
- Bachelor’s Degree in Health Informatics or Health Information Management, or equivalent
- Current AHIMA or AAPC coding credential(s)
- 5+ years coding and/or auditing experience
- Knowledge of reimbursement policies across multiple care settings
- Experience interpreting federal/state regulations, payor policies, provider contracts, coding and billing standards
- Comprehensive knowledge of Official Coding Guidelines, AHA Coding Clinic, CPT assistant
- SQL familiarity preferred
- Experience analyzing claim and audit data
- Understanding of HIPAA and safeguarding PHI/PII
- Strong communication skills
- Experience in training and presentations
- Proficient in Microsoft Office
- Able to work Eastern time zone hours
- Secure home office and reliable internet
Penstock is part of Goodroot, a community working to increase access to quality healthcare while lowering costs.
- Bachelor's Degree in Health Informatics, Health Information Management, or equivalent education and experience
- Current AHIMA or AAPC coding credential(s)
- 5+ years of coding and/or auditing experience
- Extensive knowledge of reimbursement methodologies and policies
- Experience with coding guidelines and regulations (Official Coding Guidelines, AHA Coding Clinic, CPT assistant)
- Proficiency in data analysis and interpretation
- Familiarity with SQL preferred
- Understanding of HIPAA compliance
- Excellent communication and training skills
- Proficiency in Microsoft Word, Excel, PowerPoint
- Ability to work Eastern Time zone hours
- Secure home office with reliable high-speed internet
Penstock supports an equal opportunity environment and offers remote work. The company is part of Goodroot, dedicated to systemic improvements in healthcare access and cost efficiency. Specific benefits beyond remote work or employment type are not listed.
Location
New York, US
Employment Type
Full-time
Experience Level
Senior
Salary Range
$90,000 - $120,000
Remote work allowed
Yes
Posted
2 weeks ago