Coding Investigator, Health Plans

Overview

As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, diversity, integrity, quality and trust that are integral to our mission. EO/AA

The primary function of this role is to conduct coding and billing reviews to validate claims submitted and billed. The incumbent must be willing to participate and assist in SIU fraud, waste, and abuse investigations. This incumbent will work remotely from home for Health Choice Utah, Special Investigations Unit (SIU).

Corporate Overview: University of Utah Health Hospitals and Clinics is an integrated academic healthcare system with five hospitals including a level 1 trauma center, eleven community health centers, over 1,600 providers, and a health plan serving over 200,000 members. University of Utah Health Hospitals and Clinics is nationally ranked and recognized for our academic research, quality standards and overall patient experience. In addition to our clinical delivery system, we have a School of Medicine, School of Dentistry, College of Nursing, College of Pharmacy, and College of Health providing education and training for over 1,250 providers annually. We have over 2 million patient visits annually and research grants exceeding $350 million.

Responsibilities

• Reviews post-payment and prepayment physician and institutional claims with corresponding medical records to determine accuracy of claim payments.
• Documents results and findings from reviews and provides feedback to investigators and management.
• Performs coding audits utilizing ICD-10, CPT and HCPCS coding and billing systems.
• Requires the ability to identify through investigation and analysis, underlying causes and contributing factors to the coding errors.
• Provides guidance to physicians and other staff in identifying and resolving issues or errors such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, and/or codes that do not conform to approved coding principles and guidelines.
• Reviews medical records, claims, contracts, licenses, and member benefit information.
• Serves as the medical coding subject matter expert for the Special Investigations Unit.
• Stays current with standard coding practices as well as company-wide policies and guidelines.
• Researches applicable state and federal statutes, laws, and regulations and applicable payment policies.
• Communicates and participates in meetings related to case investigations.
• Supports legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions.
• Collects, analyzes, and interprets data, both internally and externally, relating to fraud, waste, and abuse.
• Analyzes and reviews confidential and highly sensitive investigative material and documents concerning members, providers, and brokers.

Knowledge / Skills / Abilities

• Extensive knowledge of ICD-10, HCPCS and CPT coding rules and guidelines according to CMS, AMA, and other official sources.
• Knowledge of medical codes, terminology, abbreviations, anatomy and physiology.
• Self-Motivated professional who can work effectively independently with moderate oversight.
• Ability to establish and manage good relationships with internal and external stakeholders.
• Detail-oriented with strong organizational skills.
• Able to work well under deadlines in a changing environment and perform multiple tasks effectively and concurrently.
• Strong verbal/written communication skills.
• Strong critical thinking, problem solving, and analytical skills.
• Proficiency in Excel, Word, database search tools, and use of the Internet.
• Strong personal and professional ethics.
• Ability to meet the American Academy of Procedural Coders continuing education requirements.

Qualifications

QualificationsRequired

• A current AAPC or AHIMA coding certification.
• 3+ years of medical coding experience.
• A demonstrated working knowledge of local, state and federal laws and regulations pertaining to health insurance (Commercial and Medicaid Health Plans).

Qualifications (Preferred)

Preferred

• A current AAPC or AHIMA coding certification.
• 5+ years of medical coding experience.

Associate's degree or a Professional Certification including any of the following:

• Certified Coding Specialist (CCS)
• Accredited Healthcare Fraud Investigator
• Certified Fraud Specialist
• Certified Fraud Examiner

Working Conditions and Physical Demands

Employee must be able to meet the following requirements with or without an accommodation.

• This is a sedentary position that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions.

Physical Requirements

Listening, Sitting, Speaking, Standing, Walking

Multi-lingual Candidates Welcomed

Interested in this opportunity?

To inquire about this posting, email: careers@hsc.utah.edu

EEO Statement

University of Utah Health Hospitals and Clinics, a part of The University of Utah, values candidates who have experience working in settings with students from diverse backgrounds and possess a strong commitment to improving access to higher education for historically underrepresented students.

Individuals from historically underrepresented groups, such as minorities, women, qualified persons with disabilities and protected veterans are encouraged to apply. Veterans’ preference is extended to qualified applicants, upon request and consistent with University policy and Utah state law. Upon request, reasonable accommodations in the application process will be provided to individuals with disabilities.

University of Utah Health Hospitals and Clinics, a part of The University of Utah, is an Affirmative Action/Equal Opportunity employer and does not discriminate based upon race, ethnicity, color, religion, national origin, age, disability, sex, sexual orientation, gender, gender identity, gender expression, pregnancy, pregnancy-related conditions, genetic information, or protected veteran's status. The University does not discriminate on the basis of sex in the education program or activity that it operates, as required by Title IX and 34 CFR part 106. The requirement not to discriminate in education programs or activities extends to admission and employment. Inquiries about the application of Title IX and its regulations may be referred to the Title IX Coordinator, to the Department of Education, Office for Civil Rights, or both.

To request a reasonable accommodation for a disability, please contact the University of Utah Health Hospitals and Clinics Human Resources office at 801-581-6500.If you or someone you know has experienced discrimination or sexual misconduct including sexual harassment, you may contact the Director/Title IX Coordinator in the Office of Equal Opportunity and Affirmative Action:

Sherrie Hayashi

Director/ Title IX Coordinator

Office of Equal Opportunity and Affirmative Action (OEO/AA)

383 University Street, Level 1 OEO Suite

Salt Lake City, UT 84112
801-581-8365
oeo@utah.edu
Online reports may be submitted at oeo.utah.edu/
For more information: https://www.utah.edu/nondiscrimination/

The University is a participating employer with Utah Retirement Systems (“URS”). Eligible new hires with prior URS service, may elect to enroll in URS if they make the election before they become eligible for retirement (usually the first day of work). Contact Hospitals and Clinics Human Resources at (801) 581-6500 for information. Individuals who previously retired and are receiving monthly retirement benefits from URS are subject to URS’ post-retirement rules and restrictions. Please contact Utah Retirement Systems at (801) 366-7770 or (800) 695-4877 or Hospitals and Clinics Human Resources at (801) 581-6500 if you have questions regarding the post-retirement rules.

This position may require the successful completion of a criminal background check and/or drug screen.

Requisition Number 66688

Reg/Temp Regular

Employment Type Full-Time

Shift Day

Work Schedule 7:00 am - 4:00 pm

Location Name University of Utah Health Plans

Workplace Set Up Remote

City Murray

State UT

Department UIP CST 01H Compliance

CategoryHealth Plans