Job Summary:

The Vendor Medical Coding Analyst is responsible for guiding the overall efficiency and accuracy of the vendor payment process through analyzing medical records and supplemental data to ensure diagnostic and procedural codes accurately reflect and support the visit as it relates to correct coding guidelines and medical necessity. In addition, they are responsible for leading the identification of root causes of claims issues and holding vendors and internal CareSource teams accountable in implementing process improvements.

Essential Functions:

• Audit and interpret medical procedures and terminology in medical documentation to conclude if appropriate medical coding was used in vendor claims data.
• Utilize critical thinking skills, discretion and independent judgment to determine best course of action for each inquiry.
• Identify root cause of vendor payment issues and lead solutioning sessions with vendor and internal CareSource teams.
• Identify and implement process improvements based on analysis of issues and other gaps in processes.
• Conduct audits of vendor medical records.
• Assess and generate reports to determine claim impact to aid in resolution.
• Collaborate with leadership to advocate resolving issues based on industry standard coding practices.
• Act as a subject matter expert to analyze and decide the appropriate reimbursement for codes submitted on claims.
• Track status and oversee the work to conclusion as it moves through vendor and internal teams.
• Develop claims test case scenarios and test plans to ensure industry standard coding practices are implemented.
• Conduct on-going monitoring and communications to promote and ensure adherence to established protocols and best practices.
• Build and maintain cross-functional working relationships with operational departments, markets, and Quality leaders.
• Maintain an understanding of Federal and State Regulatory requirements, i.e. CMS, ODJFS and MDCH.
• Ability to interface with vendor and represent CareSource in a professional manner.
• Assist the vendors proactively by evaluating risks and developing risk-mitigation actions.
• Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, state and departmental confidentiality guidelines.
• Perform any other job related duties as requested.

Education and Experience:

• Bachelor's degree required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Three (3) years Medical billing coding experience required
• Three (3) years Managed Care experience preferred
• Three (3) years of claims payment experience required

Competencies, Knowledge and Skills:

• Knowledge of diagnosis codes, and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicare/Medicaid/Commercial reimbursement guidelines
• Intermediate level of Facets, Microsoft Word, Excel, PowerPoint and Access
• Firm understanding of basic medical billing process
• Reimbursement Methodology (APC, DRG, OPPS) preferred
• Advanced communication skills
• Data analysis and quality assurance skills
• Ability to work independently and within a team environment
• Ability to generate reports & identify trends in coding
• Attention to detail
• Familiarity of the healthcare field
• Knowledge of Medicaid/Medicare/Commercial
• Critical listening and thinking skills
• Claims processing skills
• Technical writing skills
• Time management skills
• Decision making/problem solving skills

Licensure and Certification:

• Certified Medical Coder (CPC, RHIT or RHIA) required

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• May be required to work additional hours and/or outside normal business hours as needed to meet deadlines.
• Travel is not typically required

Compensation Range:

$54,500.00 - $87,300.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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