Senior Medical Coding Auditor

Looking for a way to make an impact and help people?
Join PacificSource and help our members access quality, affordable care!
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Position Overview:
Subject matter expert on researching and resolving grievance and appeals for the commercial line of business. Utilizing expert level of adjudicator expertise, clinical interpretation and decision making. Oversees establishing and/or revising claims research policies and procedures and look for ways to improve processes. Assist with claims and processes requiring expert-level knowledge of clinical data, billing/coding, system functions and claims procedures.
Subject matter expert in identifying more complex potentially fraudulent claims. Review complex claim scenarios for final determinations. Mentor, train and direct the Medical Coding Auditor Team. Review claim documents (i.e., medical records, operative reports, and diagnostic studies) and prepare documentation for utilization reviews. Coordinate efforts to recover erroneous payments made due to processing errors, misrepresentative billing, fraud or abuse.
Essential Responsibilities:

• Participate in Provider/Member Appeals process.
• Provide expert-level guidance on claims/processes requiring a higher-level of research and analysis, including, but not limited to - initial clinical evaluations, request and review of medical records, coding assistance and research (CPT, HCPC, ICD-10), including unlisted procedures and changes in diagnosis and procedure codes.
• Advise on claims received through the Advanced Rebill queue and the Compliance queue, demonstrating an expert-level understanding of medical documentation, billing/coding, compliance, and claims processing guidelines.
• Demonstrate a lead role in system upgrades, acting as the interdepartmental point of contact for testing/support. Create/review documentation and facilitate training on changes resulting from system upgrades.
• Perform audits for tracking and reporting. Create and maintain a tracking method to share with manager and team leads for training and learning progress. Analyze audit data to identify major issues/opportunities for retraining and perform trainings as necessary.
• Proactive coaching or mentoring of others, utilizing acquired expertise and education to aid in the development of other Claims Audit Specialists.
• Advise and assist other departments regarding billing/coding guidelines, medical records review, claims processing guidelines and other issues. Provide expert-level claims-related education as necessary to Configuration Analysts, Provider Service Representatives, Sales Representatives, etc.
• Review claims received through the Advanced Rebill and Compliance queues. These claims require additional research, including, but not limited to the following:
  
  • Initial clinical evaluations
  • Request and review of medical records
  • Coding assistance and research- CPT and ICD-10, including unlisted procedures and changes in diagnosis and procedures
  • Optum Clinical Editing System review
• Develop and maintain collaborative relationships to facilitate the accomplishment of work goals
• Develop standards by which to measure progress and communicate progress with Claims teams and other departments.
• Support quality improvement initiatives, both internal and across departments.
• Document issues that affect other PacificSource departments and advise appropriate internal personnel of claims processing concerns and/or problems. Use established communication channels to notify internal departments and personnel.
• Document issues that affect claims processing quality and advise team leader of claims processing or system configuration concerns and/or problems.
• Conduct fraud, waste and abuse audits in accordance with compliance and audit work plan and prepare audit reports for management, legal counsel.
• Identify, investigate and resolve billing and coding related inquiries and complaints from beneficiaries, members, regulatory agencies and internal and external customers through demand for refund of overpayments and education to providers.
• Train staff in all coding requirements and provide all information as per institute laws and regulations.

Supporting Responsibilities:

• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.
• Interact with business leaders and users, including external partners and customers as required.
• Maintain professional, service-oriented relationships.
• Develop and track project plans for large upcoming projects that affect multiple areas.
• Collaborate with other areas on cross functional tasks.
• Lead and participate in special projects and committees as assigned.

SUCCESS PROFILE
Work Experience: Minimum 5 years claims adjudication at a claims level III or comparable experience preferred. Advanced skills in medical terminology, CPT and ICD-10 coding, and clinical background. Minimum of 2 years Fraud and Abuse audit experience in a health insurance company, healthcare provider, facility, or other relevant healthcare environment.
Education, Certificates, Licenses: Requires high school diploma or equivalent. Certified Professional Coder (CPC) and Certified Professional Medical Auditor (CPMA).
Knowledge: Thorough understanding of PacificSource products, plan designs, provider/network relationships, health insurance terminology and industry requirements. Knowledge of healthcare reimbursement regulations and provider contract language with ability to analyze implications is essential. Extensive knowledge of coding conventions and payment rules as they apply to medical record keeping, billing of medical and surgical services and healthcare reimbursement systems.
Awareness of healthcare regulatory trends, including the OIG work plan and other healthcare compliance enforcement priorities. Ability to successfully perform other coding audits to validate correct coding, which includes, but isn't limited to, CPT and HCPCs coding.
A fundamental understanding of self-insured business is helpful. Ability to read and understand health contracts, benefit language, medical records from both professional and institutional sources. Thorough understanding of claims processing system and operation. Basic working knowledge of Insurance Division rules and regulations per state. Ability to develop Lean training materials and deliver claims training to others. Moderate/high clinical interpretation skills. Team player willing to collaborate with others and help accomplish objectives. Proactive, clear, and concise communication at all levels and with all types of customers. Advanced research skills and ability to evaluate situations for appropriate resolution. Advanced computer skills including keyboarding and ten-key proficient, advanced Microsoft Word, Excel, SharePoint, and OneNote. Strong analytical and mathematical skills. Advanced understanding of healthcare reimbursement issues involved in facility, supplier, provider contracts and an extensive understanding of all types of coding applications.
Understanding of audit procedures (e.g., data collection and sampling methodologies). Ability to interact appropriately with all levels of management, especially physicians. Excellent oral and written communication and interpersonal skills. Demonstrate strong organizational and problem-solving skills.
Ability to prioritize work, perform under time constraints with minimal direct supervision, and quickly understand new information. Meet or exceed PacificSource performance expectations.
Competencies

• Adaptability
• Building Customer Loyalty
• Building Strategic Work Relationships
• Building Trust
• Continuous Improvement
• Contributing to Team Success
• Planning and Organizing
• Work Standards

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
Our Values
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.