Perform medical claim reviews for waste and error to ensure compliance with coding practices through comprehensive record review for medical and institutional providers.
The role is responsible for determining correct coding and appropriate documentation during medical record reviews while ensuring state, federal, and company requirements are met.
Key responsibilities include conducting comprehensive medical record audits, researching applicable guidelines, discussing cases with Medical Directors when needed, identifying potential billing errors and fraud indicators, preparing concise findings summaries, presenting case outcomes to internal partners, tracking recurring coding and billing issues, and maintaining accurate records and documentation.
Required Qualifications
- AAPC Certified Professional Coder (CPC) certification
- 2+ years of experience in medical coding, claims review, or auditing
- Strong knowledge of CPT, HCPCS, ICD-10, and modifiers
- Knowledge of CMS 1500 and UB04 data elements
- Ability to research coding and policy guidance
- Experience with Microsoft Excel and Word
- Strong attention to detail and ability to interpret data
- Strong written and verbal communication skills
Preferred Qualifications
- 1+ years of experience in appeal/reconsideration medical coding, claims reviews, or auditing
- Medicaid auditing experience
- Prior auditing experience in fraud, waste, abuse, error, or payment integrity
- Excellent communication skills
- Strong analytical and problem-solving skills
- EncoderPro experience
Education
- High school diploma or GED
- AAPC CPC certification
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Bonus, commission, or short-term incentive eligibility
Location
West Virginia, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$43,888 - $102,081
Remote work allowed
No
Posted
1 month ago