Senior Coding Integrity Auditor - 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.

At over a dozen Emblem Health Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit  .

Senior Coding Integrity Auditor - Remote

• 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.
• 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…