Responsible for making medical records audit payment decisions on a wide variety of claim complexities within department standards
Responsible for researching, analyzing, and making audit payment decisions on moderately complicated claims based on medical coding guidelines and policies
Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business
Responsible for meeting productivity standards while maintaining quality as outlined in SOP
Responsible for identifying and implementing process improvements and referring system enhancement ideas to manager
Collaborates with internal departments to facilitate claim processing and to come to appropriate claim resolutions
Responds to simple escalation and provider inquiries
Prepares claim audit summaries for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as needed
Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims
Responsible for identifying systemic and process issues problems/concerns and reporting them to management
Responsible for backing up administrative duties in medical record acquisition processes
Responsible for identification of training and quality areas to be shared with management
Perform any other job related duties as requested

Associates degree required
Equivalent years of relevant work experience may be accepted in lieu of required education
Three (3) years of medical bill coding required
Medicaid/Medicare experience preferred
Clinical background with a firm understanding of claims payment preferred
Experience with reimbursement methodology (APC, DRG, OPPS) preferred
Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicaid/Medicare reimbursement guidelines
Proficient in Microsoft Office Suite
Possess a general knowledge and healthcare claim payment processing
Knowledge of Facets Healthcare claim system configuration knowledge or experience is preferred
Experience reviewing medical records for the purpose of determining proper medical coding

Medical Coding Reviewer II, CPC, RHIT, RHIA

About this role