Our client's Special Investigations Unit (SIU) is currently managing a claim volume exceeding 5,000, which has significantly impacted their operational capacity. Due to existing bandwidth limitations, Elite Technical is seeking three (3) Medical Coders to help reduce the backlog and maintain timely investigative processes. This additional resourcing is essential to ensure continued compliance, mitigate risk, and uphold the integrity of our claims review process.

Responsibilities will include reviewing provider claims with medical records for SIU prepayment team. The role is to ensure properly coded claims in accordance with AMA, industry standards, and identification of FWA indicators.

Accreditations include: CPC, CPMA, COC through AAPC.

Purpose:
Acts as an internal expert to ensure that as value-based reimbursement and medical policy models are developed and implemented. Provides advanced knowledge to support effective partnership with provider entities and guidance on the appropriate quality measure capture and proper use of CPT and ICD 10 codes in claims submissions. Utilizes extensive coding knowledge, combined with medical policy, credentialing, and contracting rules knowledge to help build the effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity.

Consults on proper coding rules in value-based contracts to ensure appropriate quality measure capture and proper use of CPT and ICD10 codes. Provides input on various consequences for different financial and incentive models. Supports to use of alternatives and solutions to maximize quality payments and risk adjustment. Translates from claim language to services in an episode or capitated payment to articulate inclusions and exclusions in models.

Serves as a technical resource / coding subject matter expert for contract pricing related issues. Conducts business and operational analyses to assure payments are in compliance with contract; identifies areas for improvement and clarification for better operational efficiency. Provides problem solving expertise on
systems issues if a code is not accepted. Troubleshoots, make recommendations and answer questions on more complex coding and billing issues whether systemic or one-off.

Supports and contributes to the development and refinement of effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity. May interface directly with provider groups during proactive training events or just in time on complex claims matters. Consults with various teams, including the Practice Transformation Consultants, Medical Policy Analysts and Provider Networks colleagues to interpret coding and documentation language and respond to inquiries from providers.

Keeps up-to-date on coding rules and standards.

Required Skills

- Education Level: High School Diploma
- Experience: 3 years experience in risk adjustment coding, ambulatory coding and/or CRC coding experience in managed care; state or federal health care programs; or health insurance industry experience
- Experience in revenue cycle management and value-based reimbursement/contracting models and methodologies
- Knowledge of billing practices for hospitals, physicians and/or ancillary providers as well as knowledge about contracting and claims processing
- Knowledge and understanding of medical terminology to address codes and procedures.
- Excellent communication skills both written and verbal.
- Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and demonstrated ability to learn/adapt to computer-based tracking and data collection tools

Preferred Qualifications
- Bachelor's degree in related discipline
- Experience in medical auditing
- Experience in training/education/presenting to large groups