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 to management and recommend resolutions to increase team performance.
• Mentor Program Integrity Audit Analysts and identify training opportunities to close knowledge gaps.
• Use CPT, ICD10, HCPCS, DRG, and REV coding rules to analyze complex provider claim submissions.
• 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).
• Collaborate with cross-departmental teams including Claims, Configuration, and IT to address system gaps.

Requirements

• Associates degree or equivalent relevant work experience.
• 5 years of medical billing and coding experience.
• 3 years of SIU/FWA (Special Investigations Unit/Fraud, Waste, and Abuse) experience.
• Proven experience with claim pre-payment and medical documentation auditing.
• Extensive experience with Medicaid and Medicare guidelines.
• Required certification: CPC, RHIT, or RHIA.
• Experience with reimbursement methodologies such as APC, DRG, or OPPS.

Preferred Qualifications

• 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 improve the communities we serve.