Medical Coding Reviewer I

Position Purpose: Perform clinical/coding medical claim review to ensure compliance with coding practices through a comprehensive review and analysis of medical claims, medical records, claims history, state regulations, contractual obligations, corporate policies and procedures and guidelines established by the American Medical Association and the Centers for Medicare and Medicaid Services. Key Details: Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT. Analyze provider billing practices by utilizing code auditing software, provider documentation, administrative policies, regulatory codes, legislative directives, precedent, AMA and CMS code edit criterion Review medical records to ensure billing is consistent with medical record for appeals, adjustments and miscellaneous/unlisted code review Review cases with Medical Director to validate decisions and identify opportunities to create medical policy in the absence of guidelines Assist with research of health plan coding questions Identify potential billing errors, abuse, and fraud Identify opportunities to flag potential cases which may warrant a prepayment review (versus an automatic system denial or payment) Maintain appropriate records, files, documentation, etc Performs other duties as assigned Complie