Coding Integrity Auditor - Remote

Summary of Position

• Responsible for upholding the standard for code review functions in the setting of claims review, grievance and appeal, and new medical policy implementation.
• Identify inconsistencies between CCI & EH reimbursement policies and claim which directly impact claim payment (i.e. authorizations) and responsible for working with leadership to bring to resolution.
• Perform audit of suspended and appealed claims reviewed by coding staff.
• Perform audits of outlier providers for accurate coding practices and documentation requirements.

Principal Accountabilities

• Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment.
• Audit claim reviews and medical records to ensure accurate adjudication; review decisions from Coding Integrity team; provide feedback, results, and recommendations to management.
• Review reporting for outlier provider claims; request patient medical records to assign diagnoses, treatments, and surgical and non-surgical procedures for facility and medical services for coding and payment integrity.
• Provide direct education to the business and provider offices as needed to facilitate an understanding of correct claim coding, use of CPT, ICD-10, HCPCS, etc.
• Perform audits of changes to coding introduced by new medical policies, reimbursement policies, regulatory changes, and business requirements on a quarterly basis.
• Participate in RPC, RPCW, Medical Policy Committee (MPC) and Medical Policy Committee Workgroup (MPCW) as added Coding Integrity representation at meetings; ensure that decisions are appropriate and will result in accurate claim reimbursement.
• Identify reimbursement and coding variances from industry standards and brings to leader’s attention.
• Provide support for internal and vendor edit reviews and provider contracts.
• Perform related tasks as directed or required.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor’s degree, preferably in a healthcare, quantitative/analytical, or business-related field of study. (Required); additional years of related work experience/specialized training may be considered in lieu of educational requirements.
• AAPC CPC (AAPC Certified Professional Coder) &/or CCS (AHIMA Certified Coding Specialist). (Required)
• AAPC CPMA (AAPC Certified Professional Medical Auditor) (Required)

Relevant Work Experience, Knowledge, Skills, and Abilities

• 3 – 5+ years of coding experience. (Required)
• 1+ year auditing experience. (Required)
• Additional years of related work experience/specialized training may be considered in lieu of educational requirements. (Required)
• Proficiency with MS Office (Word, Excel, Access, PowerPoint, Outlook, Teams, etc.) (Required)
• Attention to detail; and ability to communicate or escalate issues in a timely manner. (Required)
• Ability to independently prioritize and complete multiple tasks with competing priority levels and deadlines. (Required)
• Ability to perform effectively in a fast-paced work environment. (Required)
• Excellent communication skills (verbal, written, presentation, interpersonal) with all types and levels of audiences. (Required)

• Requisition ID: 1000003419
• Hiring Range: $56,160-$99,360

Company Statement

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.

Need Assistance Applying? EmblemHealth provides reasonable accommodations to individuals with disabilities throughout the application and hiring process. If you need an accommodation, please contact [email protected] so we can support your request in accordance with applicable law.

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Security Disclosure

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Pay Disclosure

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.

EEOC Statement

We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.

Sponsorship Statement

At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.

Bachelor's degree in healthcare, quantitative/analytical, or business field (or equivalent experience); AAPC CPC and/or CCS certification; CPMA certification; 3-5+ years coding experience; 1+ year auditing experience; MS Office proficiency.

Key Responsibilities

• auditing claim coding
• reviewing medical records
• educating providers

Skills & Tools

Microsoft Word, Microsoft Excel, Microsoft Access, Microsoft PowerPoint, Microsoft Outlook, Microsoft Teams

Job Details

• Category: Healthcare Services - Allied Health
• Seniority: Mid Level
• Commitment: Full Time
• Workplace: Remote — New York City, New York, United States
• Salary: USD 56,160 – 99,360 / year
• Languages: English

About EmblemHealth

A not-for-profit health insurer serving diverse communities with commercial and government-sponsored health plans. — Industry: Healthcare