Sr Claims Reimbursement and Coding Specialist

This position conducts special and complex claim audits on all claim coding and clinical documentation investigations related to state and federal regulatory and compliance requirements, identifying issues and/or entities that may pose a risk for fraud, waste, and abuse. Identified issues and trends result in recommendations for claims process and documentation improvement and education. AAPC and/or AHIMA coding credentials are required.

To be successful in this role, you:

• Have a minimum of 5+ years medical coding/auditing experience, including minimum of 1 or more years in fraud, waste and abuse experience, or any combination of education and experience which would provide an equivalent background.
• Have a coding certification such as a CPC, and/or CCS required. Additional AHIMA and AAPC certifications considered.
• Have expert knowledge of ICD-10 and CPT, HCPC and CDT.
• Are self-motivated, analytical, detail oriented and enjoy working alone or in a team environment

Essential functions and Roles and Responsibilities:

• Examines and analyzes claims data and audits clinical documentation both prepay and post pay of providers and entities to ensure compliance with regulatory authorities (CMS, HCA and OIG) and detect and identify opportunities for fraud, waste and abuse prevention and control.
• Interpret changes in the external regulatory environment and modify CHPW policies accordingly. Keep current on regulatory and coding issues/best practices including AHA Coding Clinics and ICD-10 Official Guidelines for Coding and Reporting to aid in identifying aberrant billing issues and trends.
• Research new healthcare related questions as necessary to aid in investigations and stays abreast of current medical coding and billing issues, trends, and changes in laws/regulations.
• Collaborates and participates with regulatory authorities (HCA, CMS and OIG) as needed when related to Program Integrity audit activities.
• Design and implement process for continual review of coding documentation related to the identification of potential fraud, waste and abuse.
• Responds to all coding related inquiries from internal and external partners and is the subject matter expert on coding and code sets for the organization.
• Prepares and provides direct education to external provider partners regarding significant audit findings verbally and through written correspondence, Provider Bulletins, newsletters, and webinars as needed.
• Identifies and recommends possible interventions for improper payments and risk avoidance based on the outcome of the investigation, and/or proactive review of data.
• Collaborates with Compliance and other internal areas on matters of mutual concern to determine patterns of billing behavior.
• Reviews coding and supporting documentation and has the authority to make decisions and determinations for claim recoupment and first and second level appeals.
• Identifies and supports system configuration activities including coding editing system and benefits.
• Identifies and develops training materials for healthcare providers and trains new associates.
• Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Knowledge, Skills, and Abilities:

• Ability to review large data sets from an analytical perspective to aid in identifying potential fraud, waste and abuse.
• Ability to manage multiple cases of varying size and complexity.
• Knowledge of Medicare and Medicaid guidelines, including the CMS 1450, 1500 and ADA dental claim forms used for billing.
• Knowledge of WACs and RCWs related to healthcare.
• Advanced, applied knowledge of CPT, HCPC, CDT and ICD-CM codes, coding conventions and coding guidelines.
• Proficiency with computer business applications, and a working knowledge of electronic medical record (EMR) software.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines
• Strong analytical skills and the ability to interpret, evaluate and formulate action plans based upon data
• Time management and organization skills with the ability to manage and prioritize work to meet deadlines.
• Written and verbal communication skills; able to communicate with and collaborate effectively with physicians, CHC partners and Affiliates. Written and verbal communication skills for effective communication with all internal and external partners.
• Skilled in Microsoft Office programs including Word, Excel, and

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check.

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits:

The position is FLSA Non-Exempt and is eligible for overtime. Based on market data, this position grade is 44 and has a 5% annual incentive target based on company, department, and individual performance goals. Salary determined at offer will be based on labor market data and a candidate's years of relevant work experience and skills relevant to the position.

CHPW offers the following benefits for Full and Part-time employees and their dependents:

• Medical, Prescription, Dental, and Vision
• Telehealth app
• Flexible Spending Accounts, Health Savings Accounts
• Basic Life AD&D, Short and Long-Term Disability
• Voluntary Life, Critical Care, and Long-Term Care Insurance
• 401(k) Retirement and generous employer match
• Employee Assistance Program and Mental Fitness app
• Financial Coaching, Identity Theft Protection
• Time off including PTO accrual starting at 17 days per year.
• 40 hours Community Service volunteer time
• 10 standard holidays, 2 floating holidays
• Compassion time off, jury duty pay.

Sensory/Physical/Mental Requirements:

Sensory*:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking and possibly standing.
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.
• Frequent torso/back static position; occasional stooping, bending, and twisting.
• Some kneeling, pushing, pulling, lifting, and carrying (not over 25 pounds), twisting, and reaching.

Mental:

• Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability.

Work Environment:

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.