CareSource ir veselības apdrošināšanas uzņēmums, kas apkalpo savus biedrus, izmantojot Medicaid, Marketplace un Medicare Advantage plānus. Tā piedāvātais segums un atbalsta pakalpojumi ir paredzēti dažādām grupām, tostarp pieaugušajiem un ģimenēm ar zemiem ienākumiem, bērniem, grūtniecēm, senioriem un cilvēkiem ar invaliditāti. CareSource nodrošina arī zobārstniecības, redzes, dzirdes un aptiekas pakalpojumus, kā arī COVID-19 atbalsta resursus. Tiešsaistes un mobilie rīki palīdz biedriem pārvaldīt savu veselības aprūpi.
Senior Program Integrity Coding and Research Analyst
Serve as CareSource’s medical coding expert, leading claims audits and policy research for its Program Integrity team. Guide AI audit workflows and help improve reimbursement processes.
Apraksts
- Serve as the Program Integrity team’s medical coding expert on complex coding matters.
- Review complex provider claims using CPT, ICD-10, HCPCS, DRG, and revenue code rules.
- Find and resolve provider claim issues by examining system settings, payment policies, and claims data.
- Oversee quality audits for internal coding validation analysts and prepare monthly management reports.
- Research policy effects and explain them in light of audit type and business risk.
- Help create and carry out an annual, risk-based audit plan for high-risk providers.
- Guide claim accuracy audits from start to finish, including dispute handling.
- Set automation requirements for AI audit workflows and quality-check policy summaries, checklists, and reference materials.
- Help maintain effective internal training processes.
- Act as the main contact for provider escalations from states and markets.
- Take part in legal work, including discovery and trial preparation, and testify when needed.
- Work with markets and internal departments to resolve systemic problems and improve processes.
- Assess functional performance and recommend enhancements, cost-saving measures, and process improvements.
- Find and address inconsistencies and gaps in audit capabilities and processes.
- Identify, document, and report issues with claims reimbursement methods.
- Enter and track system change requests through the designated ticketing system.
- Represent the subject area and provide expertise in corporate meetings and projects.
- Measure and report efficiency gains or financial savings from process improvements.
- Carry out other job-related duties as requested.
Prasības
- Bachelor’s degree in business administration or a related field, or equivalent relevant work experience in place of the degree.
- At least seven years of medical coding experience, including program integrity coding audits.
- Five years of experience working with Medicaid policy in development, analysis, and consulting is preferred.
- Experience with AI tools and processes is preferred.
- Experience with reimbursement methods such as APC, DRG, and OPPS.
- Proficiency with Microsoft Office tools.
- Ability to build effective working relationships with stakeholders at all levels.
- Strong written and verbal communication skills.
- Ability to identify business problems, assess proposed solutions, and understand stakeholder needs.
- Ability to work independently and collaboratively.
- Ability to manage multiple tasks and prioritize work to meet project deadlines.
- Strong listening and critical thinking skills.
- Flexibility during organizational or business changes.
- Strong interpersonal and relationship-building skills.
- Effective problem-solving skills and attention to detail.
- Ability to lead or contribute effectively within a project team.
- Time management skills.
- Customer-service orientation.
- Decision-making and problem-solving skills.
- Ability to set priorities and achieve goals.
- Ability to coordinate and lead cross-functional teams.
- Certified Professional Coder (CPC) credential or an equivalent billing or coding designation.
- Work in a general office environment, with possible extended periods of sitting or standing.
- Travel is generally not required.
Priekšrocības
- A bonus based on company and individual performance may be available.
- A substantial, comprehensive total rewards package.
- An equal opportunity employer that supports belonging for people from all backgrounds.