Payment Integrity Coder I

As a Payment Integrity Coder I, you will support the execution of Community Health Options claim payment accuracy strategy through performing complete claim reviews. You will collaborate with the payment integrity team to ensure existing programs, such as claim editing, are working correctly. This role will require coding experience, analytical skills, and solid communication and organizational adeptness. ESSENTIAL FUNCTIONS AND 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. Performs Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements. Audits can include inpatient, outpatient, and professional claims. Coordinate with internal teams to maintain payment integrity solutions that increase claim payment accuracy. Frequently reviews other payer policies and procedures to identify gaps within the Health Options policy library, promotes areas of opportunity to appropriate stakeholders within the organization, and leads 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. Proven problem-solving skills - demonstrated ability to solve complex problems, which must consider long-term company-wide planning. Strong analytical skills - demonstrated ability to ensure reliability and relevance of data collected. Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills. Detail oriented and ability to thrive in fast-paced work environment. An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance) Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint. SQL and Datawarehouse query experience, preferred Excellent written communication skills - demonstrated ability to compose sensitive, non-routine correspondence requiring tact and diplomacy. DIVERSITY, EQUITY, AND INCLUSION STATEMENT Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces: Respectful, open communication and cooperation between all employees. Teamwork and participation, encouraging the representation of all groups and employee perspectives. Balanced approach to work culture through flexible schedules to accommodate varying needs of our people. Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other. QUALIFICATIONS AND CORE REQUIREMENTS Bachelor’s degree in business, healthcare administration, or other related functional area is required. 5+ years of experience working in health care hospital and physician practices and/or health insurance environment 3+ years of experience as a certified coder with a health plan, provider/hospital billing, or revenue cycle management. Certified Internal Auditor (CIA) preferred Certified Coding Specialist (CCS) A dedicated workspace with high-speed internet (=50 Mbps down / =10 Mbps up) and wired connectivity is required.

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