Program Integrity Coding & Research Analyst (Health Plan Experienced)
Budget / Salary$72,200–115,500
TypeFull-time job
LocationUnited States
Posted2 hours ago
Job Summary:
The Program Integrity Coding & Research Analyst acts as a Medical Coding subject matter expert for complex coding concerns and serve as primary coding resource for Program Integrity (PI).
Essential Functions:
Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions
Take a lead role to determine root cause of provider claim issues and resolve by analyzing system configuration, payment policy, and claims data
Oversight of quality audit programs for internal coding validation analysts and produce monthly reports for the managers
Researchpolicy impacts and communicate those impacts based on audit type and risk to the business
Assist in the development and implementation of an annual audit plan for providers with high risk for fraud using appropriate risk-based methodology
Act as subject matter expert for claim accuracy audits for all steps in the audit lifecycle, including disputes
Lead automation requirements for AI auditing workflows, including QA of policy summaries, checklists and other reference materials used in audits and investigations
Collaborate in maintaining effective internal training processes
Serve as primary contact for state and market escalations by providers
Participate in the preparation of legal activities which includes discovery and trial preparation and testifying as needed
Build strong working relationships with Markets and departments that are essential for resolving systemic issues and driving process improvements
Provide critical research and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
Recognize inconsistencies and gaps in audit capabilities and processes and work collaboratively to resolve the identified issues
Identify, document, and report on issues with claims reimbursement methodologies
Support the entry and tracking of system change requests, via appropriate ticketing system, for configuration or other Program and Payment Integrity improvements, act as primary resource and SME in corporate meetings and projects
Analyze and report measurable changes in efficiency or financial savings related to process improvements
Perform any other job related duties as requested.
Education and Experience:
Bachelor's degree in Business Administration or related field required
Equivalent years of relevant work experience may be accepted in lieu of required education
Seven (7) years of experience in medical coding, to include experience in program integrity coding audit required
Five (5) years of experience working with Medicaid policy in developing, analyzing and consulting preferred
Experience using AI tools and processes preferred
Experience with reimbursement methodology (APC, DRG, OPPS) required
Competencies, Knowledge and Skills:
Proficient in Microsoft Office toolset
Proven ability to establish effective working relationships with stakeholders at all different levels
Excellent written and verbal communication skills
Effective identification of business problems, assessment of proposed solutions to those problems, and understanding of the needs of stakeholders
Ability to work independently and within a team environment
Ability to multi-task and prioritize work to meet project deadlines
Effective listening and critical thinking skills
Flexibility during organizational and/or business changes
Strong interpersonal and relationship building skills
Effective problem-solving skills with attention to detail
Ability to effectively and efficiently lead and/or work within a project team
Time management skills
Customer service oriented
Decision making/problem solving skills
Ability to develop, prioritize and accomplish goals
Ability to coordinate and lead cross-functional teams
Licensure and Certification: Certified Professional Coder (CPC) or equivalent billing/coding designation required
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Travel is not typically required
Compensation Range:
$72,200.00 - $115,500.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
SalaryOrganization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
Brand=CareSourceOriginally posted on Himalayas
The Program Integrity Coding & Research Analyst acts as a Medical Coding subject matter expert for complex coding concerns and serve as primary coding resource for Program Integrity (PI).
Essential Functions:
Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions
Take a lead role to determine root cause of provider claim issues and resolve by analyzing system configuration, payment policy, and claims data
Oversight of quality audit programs for internal coding validation analysts and produce monthly reports for the managers
Researchpolicy impacts and communicate those impacts based on audit type and risk to the business
Assist in the development and implementation of an annual audit plan for providers with high risk for fraud using appropriate risk-based methodology
Act as subject matter expert for claim accuracy audits for all steps in the audit lifecycle, including disputes
Lead automation requirements for AI auditing workflows, including QA of policy summaries, checklists and other reference materials used in audits and investigations
Collaborate in maintaining effective internal training processes
Serve as primary contact for state and market escalations by providers
Participate in the preparation of legal activities which includes discovery and trial preparation and testifying as needed
Build strong working relationships with Markets and departments that are essential for resolving systemic issues and driving process improvements
Provide critical research and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
Recognize inconsistencies and gaps in audit capabilities and processes and work collaboratively to resolve the identified issues
Identify, document, and report on issues with claims reimbursement methodologies
Support the entry and tracking of system change requests, via appropriate ticketing system, for configuration or other Program and Payment Integrity improvements, act as primary resource and SME in corporate meetings and projects
Analyze and report measurable changes in efficiency or financial savings related to process improvements
Perform any other job related duties as requested.
Education and Experience:
Bachelor's degree in Business Administration or related field required
Equivalent years of relevant work experience may be accepted in lieu of required education
Seven (7) years of experience in medical coding, to include experience in program integrity coding audit required
Five (5) years of experience working with Medicaid policy in developing, analyzing and consulting preferred
Experience using AI tools and processes preferred
Experience with reimbursement methodology (APC, DRG, OPPS) required
Competencies, Knowledge and Skills:
Proficient in Microsoft Office toolset
Proven ability to establish effective working relationships with stakeholders at all different levels
Excellent written and verbal communication skills
Effective identification of business problems, assessment of proposed solutions to those problems, and understanding of the needs of stakeholders
Ability to work independently and within a team environment
Ability to multi-task and prioritize work to meet project deadlines
Effective listening and critical thinking skills
Flexibility during organizational and/or business changes
Strong interpersonal and relationship building skills
Effective problem-solving skills with attention to detail
Ability to effectively and efficiently lead and/or work within a project team
Time management skills
Customer service oriented
Decision making/problem solving skills
Ability to develop, prioritize and accomplish goals
Ability to coordinate and lead cross-functional teams
Licensure and Certification: Certified Professional Coder (CPC) or equivalent billing/coding designation required
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Travel is not typically required
Compensation Range:
$72,200.00 - $115,500.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
SalaryOrganization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
Brand=CareSourceOriginally posted on Himalayas
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