Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral health care, laboratory, etc. Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse. Position requires the associate to verify authorization for services and written documentation of services provided against claim information, ensure the appropriateness and accuracy of diagnosis and procedure codes supporting such claims, coordinate medical necessity and appropriate level of care determinations with Medical Directors, and validate services against CMS and State-specific coverage, limitations and exclusion guidelines. Coordinate with internal and external resources in determining the appropriateness of codes found in administrative, medical, claim and financial records, develop reports of findings and recommendations, communicate complex results of audit findings in meetings and/or judicial hearings, and assist SIU investigators during interviews, discussions and negotiations with providers, suppliers, and pharmacies.
DEPARTMENT: SIU AND CORPORATE INVESTIGATIONS
REPORTS TO: MANAGER OF REPORTING AND ANALYTICS
- Audits, assesses, identifies, reviews, and monitors providers, suppliers, and pharmacies to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral health care, laboratory, etc. medical records, and independently codes, abstracts and analyzes inpatient and outpatient medical records using most current International Classification of Diseases (ICD-9/ICD-10), Current Procedural Terminology (CPT), Health Care Common Procedure Coding System (HCPCS), Universal Billing (UB) and other codes, according to federal, CMS, and state statutory, regulatory and contractual requirements, AMA guidelines, and generally accepted coding practices.
- Verifies and validates authorization of services, written clinical documentation of services received through health services and health utilization management departments, and information contained in the health care claim systems against claims, medical records and other documentation submitted by the provider, and identifies coding errors, inconsistencies, anomalies, abnormal billing patterns, and other indicators (e.g., services not rendered, up-coding, un-bundling, etc.) of suspected fraud and abuse.
- Coordinates individual work activities with SIU investigators, develops and presents findings and recommendations regarding the appropriateness of diagnosis and procedure codes submitted on provider service claims, and supports overpayment recovery during discussions with medical and behavioral health care providers.
- Manages large caseloads involving audits of statistically valid random samples of claims and completes a review findings spreadsheet and summary for the investigative case file and updates system entries with review findings. Communicates complex results of audit findings in meetings and/or judicial hearings.
- Educates providers, suppliers, and pharmacies and administrative support staff at all levels on CMS, federal and state statutory, regulatory and contractual requirements, appropriate coding according to AMA guidelines, acceptable practice standards, and procedures for preventing and reporting potential fraud and abuse.
- Coordinates coding and payment issues with other areas and departments as required. Supports and participates in process and quality improvement initiatives.
- Presents educational seminars on fraud and abuse awareness, detection and reporting to areas and departments as required.
- Present findings and provide testimony in legal proceedings as required.
- Performs other duties as assigned.
- Required a High School or GED
- Preferred a Bachelor's Degree in a related field
- Required 3 years of experience in Healthcare coding directly related to determining appropriate diagnosis, procedure and other codes used in billing for services, utilization management, medical record auditing, or health care quality improvement is required
- Preferred knowledge and experience working in the government sector of the managed health care industry
Licenses and Certifications:
- Intermediate knowledge of community, state and federal laws and resources
- Intermediate strong organizational, interpersonal, communications skills
- Intermediate efficiently manages multiple priorities, is inquisitive, energetic, and takes initiative
- Intermediate ICD-10 proficient
A license in one of the following is required:
- Required 3 years as a Certified Coding Specialist (CCS), Certified Coding Specialist Provider-based (CCS-P), Certified Professional Coder (CPC or CPC-H), or equivalent certification is required.
- Preferred Certified Professional Medical Auditor (CPMA)
- Preferred Licensed Practical Nurse (LPN)
- Required intermediate Microsoft Excel
- Required intermediate Microsoft Access
- Required intermediate Microsoft Word
- Required intermediate Microsoft Outlook
- Required intermediate Microsoft Visio
- Required intermediate Microsoft PowerPoint