Job Information
AmeriHealth Caritas Medical Coding Auditor | Certification Required (Remote, USA) in Remote, United States
Medical Coding Auditor | Certification Required (Remote, USA)
Location: Remote, United States
Primary Job Function: Compliance
ID**: 31604
*Must be permanently authorized to work in the U.S. as a precondition of employment. :
Your career starts now. We are looking for the next generation of health care leaders.
At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com.
Responsibilities:
The Provider Claims Inquiry Team Medical Coding Auditor reviews medical records and documents supporting claims for Physical and Behavioral Health Services. Manages and conducts specific medical billing and coding audits to evaluate the completeness of medical record documentation, identifies aberrant coding and billing patterns, and provides feedback to the Clinical and Investigative staff on coding and compliance issues. The incumbent provides investigative support related to coding and billing issues. The Provider Claims Inquiry Team identifies potential overpayments due to suspected healthcare fraud and abuse.
Reviews medical and behavioral health care medical records and independently codes, abstracts, and analyzes Inpatient and Outpatient medical records using the most current International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT), Health Care Common Procedure Coding System (HCPCS), Universal Billing (UB) and other codes according to federal and state statutory, regulatory and contractual requirements, AMA guidelines and generally accepted coding practice.
Verifies and validates authorization of services, written clinical documentation of services received through Physical Health Services and Behavioral Health utilization management Departments, and information contained in the health care claims systems against claims, medical records, anomalies, abnormal billing patterns, and other indicators (e.g., services not rendered, up-coding, unbundling, etc.) of suspected fraud and abuse.
Coordinates individual work activities with Research Analysts, develops and presents findings and recommendations regarding the appropriateness of diagnosis and procedure codes submitted on provider service claims, and supports overpayment recovery during discussions with medical and behavioral health care providers.
Coordinates coding and payment issues with other areas and departments as required.
Provides a detailed written review of audit findings to management, plan representatives, and State Regulatory Agencies.
Presents findings and provides testimony in legal proceedings as required.
Must be able to use data analysis and extraction tools to evaluate transactions and identify potential billing errors or misstatements.
Ability to integrate current industry changes into a clinical audit practice setting.
Understands anatomy and physiology, disease process, medical terminology, and pharmacology.
Works independently following established policies, procedures, and practices.
Consistently and positively communicates and collaborates with colleagues, supervisors, managers, and customers, both internal and external.
Performs all other duties as assigned and within given timeframes.
Education/ Experience:
Required High school diploma; Bachelor’s Degree preferred.
Successful completion of at least one AHIMA or AAPC certification program with the achievement of the correlating professional credential (CPC, CCS, or CCS-P); active and in good standing.
Required 1-3 years of hands-on medical records for diagnosis/ medical condition coding.
ICD-10 proficiency validation. HCC coding experience is a plus.
Proven knowledge of Medicare and Medicaid guidelines, along with an understanding of federal and state laws and regulations in medical reimbursement.
Proficiency with Microsoft applications is required. Knowledge of EXP/Macess, Excel, Cors, and Facets is highly preferred (e.g. essential for document finding, route service forms, vendor communication, etc.)
Must listen respectfully and carefully, demonstrating flexibility in working with others, and must efficiently and independently plan time, meet deadlines, initiate, and follow through on tasks.
Diversity, Equity, and Inclusion
At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
We keep our associates happy so they can focus on keeping our members healthy.
Our Comprehensive Benefits Package
Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.
EOE Minorities/Females/Protected Veterans/Disabled