Medical Coding Reviewer III

Responsibilities

• Support complex medical record audit programs, dispute management, and escalation management.
• Generate in-depth reporting and analysis for Pre-Pay and Post-Paid processes to track performance.
• Provide production and progress reports and recommend process improvements to management.
• Mentor Program Integrity Audit Analysts and identify training opportunities for team members.
• Use CPT, ICD10, HCPCS, DRG, and REV coding rules to analyze complex provider claims.
• Research and interpret state-specific Medicaid, federal Medicare, and ACA/Exchange laws and guidelines.
• Make claim audit payment decisions for highly complicated scenarios using medical coding guidelines.
• Refer suspected Fraud, Waste, or Abuse (FWA) to the Special Investigations Unit (SIU).

Requirements

• Associates degree or equivalent relevant work experience.
• Five (5) years of medical billing and coding experience.
• Minimum of three (3) years of SIU/FWA medical billing and coding experience.
• Proven experience with claim pre-payment and medical claim/documentation auditing.
• Extensive experience with Medicaid and Medicare guidelines.
• Experience with reimbursement methodologies such as APC, DRG, or OPPS.
• Required certification: CPC, RHIT, or RHIA at the time of hire.

Preferred Qualifications

• Three (3) years of experience working with Facets.
• Inpatient coding experience.
• Previous leadership or mentoring experience.

About the Company

CareSource is a mission-driven organization dedicated to creating a better world for members, stakeholders, and providers. We combine compassionate care with business expertise to provide consumer-centric solutions and support the well-being of the communities we serve.