Remote Lead Coding Analyst (RN or LPN) – New York
Job Overview
- Clinical License LPN, RN
- State(s) NY
Summary of Position
- Direct the standard for code review functions in the setting of authorizations, claims review, grievance and appeal, and new medical policy implementation.
- Ensure the quality and productivity of appeals and work queues of coders.
- Develop and design proposed coding review functions for insourcing current vendor prepay and post payment coding reviews.
- Manage EmblemHealth responses to audits and inquiries by external agencies.
- Support analyses for the Special Investigations Unit and Legal Department.
Principal Accountabilities
- Develop and implement changes for insourcing coding reviews from vendors.
- Design plans and processes to ensure clinical documentation supports coding and billing.
- Develop and maintain analytics and payment integrity savings reports regarding clinical documentation reviews.
- Represent departmental positions at meetings of, and correspondence with, the Reimbursement Policy Committee.
- Analyze and report outcomes measures for coding changes by external vendors.
- Provide the internal responses to complex problems including legal issues, special investigations, claims denials by provider groups.
- Review claims, ensure accurate charge capture and review medical necessity for coders.
- Develop guidelines for coding and documentation to ensure physician and hospital compliance.
- Act as a clinical coding liaison between the utilization management, medical directors, and coding functions.
- Serve as a resource for coding function in the Medical Utilizations Review Unit to ensure proper level of coding and payment of medical claims as a subject matter expert.
- Collaborate with clinical administration on coding and reimbursement implications of care management programs.
- Manage a partial caseload of claims reviews.
- Ensure prompt and accurate responses to all internal partners.
- Maintain productivity and quality measures for the coding review function within the department.
- Demonstrate expertise in ICD-10-CM/PCS coding to act as a resource for the education of provider, nursing, and healthcare staff, as well as new employees.
- Present findings to senior management and external parties.
- Train staff as they enter the department in all areas of coding and analysis.
- Research, review, and analyze new medical procedures, technology, equipment, and corresponding CPT/HCPCS (Healthcare Common Procedure Coding System) codes; gather input from providers; recommend coverage and reimbursement levels consistent with state and federal policies.
Qualifications
Education, Training, Licenses, Certifications
- Bachelor’s degree, preferably in a healthcare/business/quantitative science field of study. (Required); Additional experience/specialized training may be considered in lieu of educational requirements.
- CCS (AHIMA Certified Coding Specialist or CPC (AAPC Certified Professional Coder). (Required)
- Current and active RN or LPN license. (Required)
- Clinical Documentation Reviewer certification (through AAPC or ADCIS. (Required)
Relevant Work Experience, Knowledge, Skills, and Abilities
- 5 – 8+ years of relevant, professional work experience. (Required)
- 5+ years of coding experience. (Required)
- 1 year management or leadership experience in a healthcare environment. (Preferred)
- Strong analytic and organization abilities, along with effective presentation and collaboration skills. (Required)
- Proficient with MS Office (Word, Excel, Access, PowerPoint, Outlook). (Required)
- Ability to manage multiple priorities. (Required)
- Excellent verbal and written communication and interpersonal skills. (Required)
Additional Information
