Lead Coding Analyst; RN or LPN; Remote

Emblem Health 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, Emblem Health partners with top hospitals and doctors, including its own Advantage Care Physicians, to deliver quality, affordable, convenient care.

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• Direct the standard for code review functions in the setting of authorizations, claims review, grievance and appeal, and new medical policy implementation.
• Ensure the quality and productivity of appeals and work queues of coders.
• Develop and design proposed coding review functions for in sourcing current vendor prepay and post payment coding reviews.
• Manage Emblem Health responses to audits and inquiries by external agencies.
• Support analyses for the Special Investigations Unit and Legal Department.

Principal Accountabilities

• Develop and implement changes for in sourcing coding reviews from vendors.
• Design plans and processes to ensure clinical documentation supports coding and billing.
• Develop and maintain analytics and payment integrity savings reports regarding clinical documentation reviews.
• Represent departmental positions at meetings of, and correspondence with, the Reimbursement Policy Committee.
• Analyze and report outcomes measures for coding changes by external vendors.
• Provide the internal responses to complex problems including legal issues, special investigations, claims denials by provider groups.
• Review claims, ensure accurate charge capture and review medical necessity for coders.
• Develop guidelines for coding and documentation to ensure physician and hospital compliance.
• Act as a clinical coding liaison between the utilization management, medical directors, and coding functions.
• Serve as a resource for coding function in the Medical Utilizations Review Unit to ensure proper level of coding and payment of medical claims as a subject matter expert.
• Collaborate with clinical administration on coding and reimbursement implications of care management programs.
• Manage a partial caseload of claims reviews.
• Ensure prompt and accurate responses to all internal partners.
• Maintain productivity and quality measures for the coding review function within the department.
• Demonstrate expertise in ICD-10-CM/PCS coding to act as a resource for the education of provider, nursing, and healthcare staff, as well as new employees.
• Present findings to senior management and external parties.
• Train staff as they enter the department in all areas of coding and analysis.
• Research, review, and analyze new medical procedures, technology, equipment, and corresponding CPT/HCPCS (Healthcare Common Procedure Coding System) codes; gather input from providers; recommend coverage and reimbursement levels consistent with state and federal policies.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor’s degree, preferably in a healthcare/business/quantitative science field of study. (Required);
  Additional…