Note: The job is a remote job and is open to candidates in USA. EmblemHealth is hiring a Lead Coding Analyst to direct coding review standards across authorizations, claims, appeals, and medical policy implementation. The role oversees coding quality and productivity, develops coding review and payment-integrity processes, manages responses to external audits, and supports investigations and legal analyses.
Responsibilities
- Develop and implement changes for insourcing coding reviews from vendors
- Design plans and processes to ensure clinical documentation supports coding and billing
- Develop and maintain analytics and payment integrity savings reports regarding clinical documentation reviews
- Represent departmental positions at meetings of, and correspondence with, the Reimbursement Policy Committee
- Analyze and report outcomes measures for coding changes by external vendors
- Provide the internal responses to complex problems including legal issues, special investigations, claims denials by provider groups
- Review claims, ensure accurate charge capture and review medical necessity for coders
- Develop guidelines for coding and documentation to ensure physician and hospital compliance
- Act as a clinical coding liaison between the utilization management, medical directors, and coding functions
- Serve as a resource for coding function in the Medical Utilizations Review Unit to ensure proper level of coding and payment of medical claims as a subject matter expert
- Collaborate with clinical administration on coding and reimbursement implications of care management programs
- Manage a partial caseload of claims reviews
- Ensure prompt and accurate responses to all internal partners
- Maintain productivity and quality measures for the coding review function within the department
- Demonstrate expertise in ICD-10-CM/PCS coding to act as a resource for the education of provider, nursing, and healthcare staff, as well as new employees
- Present findings to senior management and external parties
- Train staff as they enter the department in all areas of coding and analysis
- Research, review, and analyze new medical procedures, technology, equipment, and corresponding CPT/HCPCS (Healthcare Common Procedure Coding System) codes; gather input from providers; recommend coverage and reimbursement levels consistent with state and federal policies
Skills
- Bachelor's degree, preferably in a healthcare/business/quantitative science field of study
- Additional experience/specialized training may be considered in lieu of educational requirements
- CCS (AHIMA Certified Coding Specialist or CPC (AAPC Certified Professional Coder)
- Current and active RN or LPN license
- Clinical Documentation Reviewer certification (through AAPC or ADCIS
- 5 – 8+ years of relevant, professional work experience
- 5+ years of coding experience
- Strong analytic and organization abilities, along with effective presentation and collaboration skills
- Proficient with MS Office (Word, Excel, Access, PowerPoint, Outlook)
- Ability to manage multiple priorities
- Excellent verbal and written communication and interpersonal skills
- 1 year management or leadership experience in a healthcare environment
Company Overview