Summary of Position
- Responsible for upholding the standard for code review functions in the setting of business/industry/legislative issues relating to, and impacting, quality coding audit and compliance issues.
- Identify inconsistencies and coding compliance risks between EH reimbursement policies and claims which directly impact claim payment (i.e. authorizations) and responsible for working with leadership to bring to resolution.
- Audit inpatient and outpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed.
Principal Accountabilities
- Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment.
- 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.
- Analyze and audit claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
- Identify potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
- Provide audit reporting, results, and recommendations to management and SIU as appropriate.
- Analyze results to assess compliance with regulations, identify procedural weaknesses and education needs that contribute to instances for non-compliance both to business, external business partners, and providers.
- Prepare formal written reports summarizing current state (findings), desired future state, and critical success factors.
- 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.
- Continuously gains knowledge of CPT, ICD, HCPCS and business/industry/legislative issues relating to and impacting Quality Coding Audit and Compliance issues.
- 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)
- AAPC CPC (AAPC Certified Professional Coder) & AAPC CIC (Certified Inpatient Coder)/or CCS (AHIMA Certified Coding Specialist) (Required)
- AAPC CPMA (AAPC Certified Professional Medical Auditor) (Required)
Relevant Work Experience, Knowledge, Skills, and Abilities
- 4 - 6+ years of coding experience. (Required)
- 1+ year auditing experience. (Required)
- Extensive knowledge of inpatient DRG clinical documentation review. (Required)
- Additional 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)
Additional Information
- Requisition ID: 1000003438
- Hiring Range: $68,040-$118,800
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EmblemHealth
Nov 05, 2026