Program Integrity Coding & Research Analyst – Health Plan Experienced

Job not on LinkedIn

🔥 16 hours ago

🇺🇸 United States – Remote

💵 $72.2k - $115.5k / year

⏰ Full Time

🟠 Senior

🔴 Lead

🔬 Research Analyst

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Act as a Medical Coding subject matter expert for complex coding concerns and serve as primary coding resource for Program Integrity • Analyze complex provider claims submissions using CPT, ICD10, HCPCS, DRG, and REV coding rules • Determine root causes of provider claim issues and resolve them by analyzing system configuration, payment policy, and claims data • Oversee quality audit programs for internal coding validation analysts and produce monthly reports for managers • Research policy impacts and communicate those impacts based on audit type and business risk • Assist in developing and implementing an annual risk-based audit plan for high-risk providers • Act as subject matter expert for claim accuracy audits throughout the audit lifecycle, including disputes • Lead automation requirements for AI auditing workflows, including quality assurance of policy summaries, checklists, and reference materials • Collaborate in maintaining effective internal training processes • Serve as primary contact for state and market provider escalations • Participate in legal activities, including discovery, trial preparation, and testifying as needed • Build working relationships with Markets and departments to resolve systemic issues and drive process improvements • Research and analyze functional performance and recommend enhancements, cost savings initiatives, and process improvements • Identify and resolve inconsistencies and gaps in audit capabilities and processes • Identify, document, and report issues with claims reimbursement methodologies • Support entry and tracking of system change requests through the appropriate ticketing system • Act as primary resource and subject matter expert in corporate meetings and projects • Analyze and report measurable efficiency or financial savings related to process improvements • Perform other job-related duties as requested

🎯 Requirements

• Bachelor's degree in Business Administration or related field required, or equivalent years of relevant work experience in lieu of required education • Seven (7) years of experience in medical coding, including program integrity coding audit experience required • Five (5) years of experience working with Medicaid policy in developing, analyzing and consulting preferred • Experience using AI tools and processes preferred • Experience with reimbursement methodology (APC, DRG, OPPS) required • Proficient in Microsoft Office toolset • Proven ability to establish effective working relationships with stakeholders at all different levels • Excellent written and verbal communication skills • Effective identification of business problems, assessment of proposed solutions, and understanding of stakeholder needs • Ability to work independently and within a team environment • Ability to multi-task and prioritize work to meet project deadlines • Effective listening and critical thinking skills • Flexibility during organizational and/or business changes • Strong interpersonal and relationship building skills • Effective problem-solving skills with attention to detail • Ability to effectively and efficiently lead and/or work within a project team • Time management skills • Customer service oriented • Decision making/problem solving skills • Ability to develop, prioritize and accomplish goals • Ability to coordinate and lead cross-functional teams • Certified Professional Coder (CPC) or equivalent billing/coding designation required • General office environment; may be required to sit or stand for extended periods of time • Travel is not typically required

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Substantial and comprehensive total rewards package • Equal Opportunity Employer environment fostering belonging and support for individuals of all backgrounds