Community Health Options
Overview
Position: Payment Integrity Coder I
Support the execution of Community Health Options claim payment accuracy strategy through performing complete claim reviews. Collaborate with the payment integrity team to ensure existing programs, such as claim editing, are working correctly. This role requires coding experience, analytical skills, and strong communication and organizational abilities.
Responsibilities
Serve as a subject matter expert for claim payment accuracy including pre-payment claim editing, pre-payment claims auditing, contract compliance, post-payment payment integrity solutions, etc.
Review appropriateness of services/supplies billed with respect to the patient’s medical condition and contemplate commercially reasonable claim-related edits to be applied in both pre- and post-pay situations.
Perform quality audits to validate the accuracy and completeness of ICD, Rev Code, CPT, HCPCS, APR, DRG, POA, and other relevant coding elements. Audits may include inpatient, outpatient, and professional claims.
Coordinate with internal teams to maintain payment integrity solutions that increase claim payment accuracy.
Review other payer policies and procedures to identify gaps within the Health Options policy library, promote opportunities to stakeholders, and contribute to reimbursement-specific policy development.
Participate in technology/tool updates, testing, and troubleshooting with internal teams and external vendors.
Manage the scope of multiple inquiries, projects, or audits under minimal direct supervision.
Job-Specific Competencies (KSAs)
Proven problem-solving skills with the ability to address complex, long-term company-wide considerations.
Strong analytical skills and ability to ensure reliability and relevance of data.
Excellent interpersonal, verbal, and written communication skills; detail-oriented and able to thrive in a fast-paced environment.
Knowledge of Local, State & Federal health insurance laws and regulations (Medicare, Medicare Advantage, Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance).
Advanced knowledge of Microsoft Office (Word, Excel, PowerPoint).
SQL and Data Warehouse query experience preferred.
Excellent written communication skills for sensitive, non-routine correspondence requiring tact and diplomacy.
Diversity, Equity, and Inclusion (DEI) Statement Community Health Options is committed to fostering a culture of diversity, equity, and inclusion (DEI). Our human capital is a valuable asset, and our DEI initiatives apply to recruitment and selection, compensation and benefits, professional development, promotions, transfers, and the ongoing development of an inclusive work environment.
Benefits DEI initiatives include: respectful, open communication; teamwork and representation of diverse perspectives; flexible schedules to accommodate varying needs; and collaboration with communities we serve to promote greater understanding and respect.
Qualifications And Core Requirements
Bachelor’s degree in business, healthcare administration, or a related area.
5+ years experience in health care hospital and physician practices and/or health insurance environment.
3+ years experience as a certified coder with health plan, provider/hospital billing, or revenue cycle management.
CIA certification preferred.
CCS certification.
A dedicated workspace with high-speed internet (≥50 Mbps down, ≥10 Mbps up) and wired connectivity is required.
Location: Maine, United States
Compensation: $17.00-$22.00 per hour
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Support the execution of Community Health Options claim payment accuracy strategy through performing complete claim reviews. Collaborate with the payment integrity team to ensure existing programs, such as claim editing, are working correctly. This role requires coding experience, analytical skills, and strong communication and organizational abilities.
Responsibilities
Serve as a subject matter expert for claim payment accuracy including pre-payment claim editing, pre-payment claims auditing, contract compliance, post-payment payment integrity solutions, etc.
Review appropriateness of services/supplies billed with respect to the patient’s medical condition and contemplate commercially reasonable claim-related edits to be applied in both pre- and post-pay situations.
Perform quality audits to validate the accuracy and completeness of ICD, Rev Code, CPT, HCPCS, APR, DRG, POA, and other relevant coding elements. Audits may include inpatient, outpatient, and professional claims.
Coordinate with internal teams to maintain payment integrity solutions that increase claim payment accuracy.
Review other payer policies and procedures to identify gaps within the Health Options policy library, promote opportunities to stakeholders, and contribute to reimbursement-specific policy development.
Participate in technology/tool updates, testing, and troubleshooting with internal teams and external vendors.
Manage the scope of multiple inquiries, projects, or audits under minimal direct supervision.
Job-Specific Competencies (KSAs)
Proven problem-solving skills with the ability to address complex, long-term company-wide considerations.
Strong analytical skills and ability to ensure reliability and relevance of data.
Excellent interpersonal, verbal, and written communication skills; detail-oriented and able to thrive in a fast-paced environment.
Knowledge of Local, State & Federal health insurance laws and regulations (Medicare, Medicare Advantage, Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance).
Advanced knowledge of Microsoft Office (Word, Excel, PowerPoint).
SQL and Data Warehouse query experience preferred.
Excellent written communication skills for sensitive, non-routine correspondence requiring tact and diplomacy.
Diversity, Equity, and Inclusion (DEI) Statement Community Health Options is committed to fostering a culture of diversity, equity, and inclusion (DEI). Our human capital is a valuable asset, and our DEI initiatives apply to recruitment and selection, compensation and benefits, professional development, promotions, transfers, and the ongoing development of an inclusive work environment.
Benefits DEI initiatives include: respectful, open communication; teamwork and representation of diverse perspectives; flexible schedules to accommodate varying needs; and collaboration with communities we serve to promote greater understanding and respect.
Qualifications And Core Requirements
Bachelor’s degree in business, healthcare administration, or a related area.
5+ years experience in health care hospital and physician practices and/or health insurance environment.
3+ years experience as a certified coder with health plan, provider/hospital billing, or revenue cycle management.
CIA certification preferred.
CCS certification.
A dedicated workspace with high-speed internet (≥50 Mbps down, ≥10 Mbps up) and wired connectivity is required.
Location: Maine, United States
Compensation: $17.00-$22.00 per hour
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