Performs quality assurance auditing of WellCare's Medical Coding Specialists and external vendors that review provider medical records for coding reviews. Conducts coder education and training to ensure accurate medical coding and provider coding denials or approvals. Owns accountability for the auditing process and other outside audits.
- Audits external vendors' coding based on medical record reviews.
- Acts as the subject matter experts (SME) for correct coding.
- Conducts coder education and training to help to ensure accurate CMS payment and to improve quality of care.
- Conducts all activities in relation to audits: medical record review, identifies best medical record, submits all necessary paperwork, responds to all inquiries and provides expertise and support during the appeals process.
- Works on additional coding audit requests (i.e. outside auditors' requests).
- Sits on the Medical Coding Specialists Help Desk with the ability to research coding questions through approved industry publications and to provide expert guidance.
- Perform other duties as necessary.
- Works in conjunction with other departments to include appeals, claims, and Corr PRT.
- Analyzes data to identify patterns and development of interventions at the provider and market level to coordinate an educational work plan for WellCare contracted providers.
- Perform quality assurance auditing (i.e. ensure appropriateness and accuracy of ICD-9/ICD-10 coding) for WellCare's Medical Coding Specialists.
- Communicates QA results to the Medical Coding Specialists with suggestions for improvement and re-training topics.
- Required 3 years of experience in a hospital or physician setting
- Required 3 years of experience in coding
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate Demonstrated analytical skills
- Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
- Intermediate Knowledge of healthcare delivery
- Intermediate Ability to represent the company with external constituents
- Intermediate Demonstrated written communication skills
- Intermediate Demonstrated organizational skills
- Intermediate Ability to work as part of a team
- Intermediate Ability to work independently
Licenses and Certifications:
A license in one of the following is required:
- Required Certified Professional Coder (CPC), CCS, or RHIA
- Preferred Certified Professional Medical Auditor (CPMA) CPC required
- Required Intermediate Microsoft Outlook Knowledge in Microsoft Office including Outlook, Word, Excel, Visio, and Power Point
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Visio
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft PowerPoint