Coding Audit Specialist, Health Plan

This is a fully remote position, open to applicants in South Dakota, +1 more state.

📋 Description

• Execute quality assurance tasks to guarantee the precision and integrity of risk adjustment data submitted to CMS and DHS.

• Detect coding deficiencies and provide management with analysis of results along with tools to enhance coding accuracy.

• Design, implement, and oversee a continuous monitoring program for Medicare Advantage, ACA/Exchange, and Medicaid/BadgerCare Plus diagnosis documentation.

• Review medical record documentation to uncover uncoded or incorrectly coded diagnoses.

• Assess coding for visits and procedures across various specialties and subspecialties related to HCC coding.

• Maintain up-to-date knowledge of coding regulations, codes, documentation guidelines, CMS policies, and reimbursement standards.

• Contrast provider documentation with reported code requirements to confirm coding support.

• Develop audit outcomes and present findings in clear, logical summaries.

⛳️ Requirements

• A high school diploma or equivalent is required.

• Proven knowledge of anatomy/physiology and medical terminology.

• Completion of courses in Current Procedural Terminology and ICD-9 and ICD-10 coding is required.

• A minimum of three years of experience in a health insurance, compliance, quality assurance, or auditing-related role.

• Proficiency in ICD-9, ICD-10, CPT, HCC, and HCPCS coding.

• Understanding of CMS guidelines that pertain to Medicare Advantage, HHS-ACA, and DHS/BadgerCare Plus members.

• Demonstrated proficiency in Word, Excel, and Access.

• Certification as a Professional Coder and/or Certified Risk Adjustment Coder from the American Academy of Professional Coders is required within one year of hire.

• An Associate Degree in coding and/or a health-related discipline is preferred.

🏝️ Benefits

• Comprehensive health insurance and wellness programs.

• Opportunities for professional development and continuing education.

• Flexible work schedules and remote work options.

• Retirement savings plan with company match.