Claim Review Specialist – Coding Certification Required

This is a fully remote position, open to applicants in United States.

📋 Description

• Support the Director of HIM in conducting claim audits, assessing and suggesting coding, revenue cycle, and billing modifications on outpatient and Profee claims for client hospitals using our proprietary software.

• Utilize software to create standardized reports, engage with clients, address coding inquiries in clear and grammatically correct English, and offer assistance to other members of the revenue cycle consulting team.

• Provide client education, prepare written FAQ responses, and carry out other assigned tasks.

• Achieve proficiency in the PARA Data Editor, our proprietary software; select and assess claims for review based on trend analysis in the PARA Data Editor; organize information and access medical documentation.

• Conduct audits on all aspects of claims including, but not limited to: - Omitted or incorrect charges, - Review OPPS and CAH charges and adhere to guidelines.

• Adhere to CMS/Payer specific guidelines - Ensure coding accuracy for ICD-10 CM, CPT/HCPCS (including but not limited to 10000-69999, 80000, 90000, J codes, G codes, Q codes, etc.).

• Perform departmental reviews for inaccuracies, omitted data/documentation and charges - NCCI edits, MUE edits, Medi-Cal and Medicare guidelines/CMS Manual guidance, - Units of services - E/M Profee/Facility - Units of services - Documentation improvement.

• Assist in drafting written documents for publication under the guidance of the Director, HIM, such as Q&A entries.

• Cultivate a working understanding of the outpatient hospital reimbursement process, encompassing documentation, coding, and billing.

• Engage in presentations to clients and prospective clients, typically conducted via web meetings.

• Develop and sustain the skills and knowledge pertinent to the assigned specialty areas and related services.

⛳️ Requirements

• Active AAPC or AHIMA coding certification (CPC, COC, CIC, CCS, RHIT, RHIA) - apprentice certifications (i.e.: CPC-A) are not acceptable.

• Experience in coding and/or auditing - OP facility (ER, I&I, OBS, SDS, E/M facility) and Profee; IP facility coding experience is a bonus.

• Over 5 years of relevant experience.

• In-depth knowledge of revenue cycle and outpatient coding (ER, SDS, OBS, ancillary, IR, Profee, E/M facility, I&I).

• CCS, COC, or CPC certification is mandatory.

• Familiarity with medical terminology and anatomy is essential.

• Experience in clinical documentation and inpatient coding is preferred.

• Strong comprehension of revenue cycle, CMS Manual/guidelines, and Medicaid guidelines.

• Proficient in Microsoft Excel, PowerPoint, Word, and OneNote.

• Comprehensive understanding of the Official Coding Guidelines, outpatient coding, and billing (including but not limited to rev codes, HCPCS, MUE and CCI edits, UoS, and ICD-10 CM).

• Possess strong analytical skills, independent thinking, and effective decision-making abilities.

• Excellent written, verbal communication, and presentation skills.

• Strong computer and technology skills.

• Maintain a highly professional demeanor and excel in client satisfaction.

🏝️ Benefits

• We foster long-term careers by investing in YOU.

• Opportunities for professional development.