JOB SUMMARY: The Certified Medical Coder will lead administrative and operational support tasks that require independent review and judgment relative to coding concerns. The Certified Medical Coder performs reviews of claim lines flagged by Community's Special Investigation Unit against medical records to determine the appropriateness of the claim. The coder will review claims data to ensure that assigned codes and supplies meet state, federal, and health plan guidelines. The Certified Medical Coder will conduct research, including a review of medical records, and correspond with the appropriate claims or medical management staffing personnel.

JOB SPECIFICATIONS AND CORE COMPETENCIES:
SIU Prepayment Review and Claims Evaluation
Perform SIU Prepayment Reviews, including medical record reviews, identifying providers for prepayment review, and evaluating compliance.
Update the cost tracker for prepayment review activity.
Process and adjudicate claims received for reimbursement to providers based on SIU review as needed.

Appeals and Payment Disputes Support
Assist with appeals and payment disputes or denials.
Review clinical documentation used in decision-making to support the validity of billed codes.
Collaborate with Claims Operations and Medical Management to ensure appropriate documentation and coding were submitted.

Regulatory and Coding Compliance
Maintain current knowledge of Centers for Medicare and Medicaid Services (CMS) requirements.
Apply Correct Coding Initiative (CCI) edits, Hospital-Acquired Conditions (HACs), and applicable National and Local Coverage Determinations (NCDs/LCDs).
Ensure use of appropriate modifiers and compliance with all regulatory coding guidelines.

Provider Inquiry and Communication Management
Field provider inquiries related to prepayment review.
Create prepayment review provider letters and handle responses in a professional and timely manner.

Claims Operations Collaboration and Support
Serve as a knowledge expert to assist Claims Operations.
Provide follow-up and recommendations related to claim denials to ensure resolution and prevent recurrence.

Actively contributes to the achievement of departmental goals, as identified in the Department's annual business plan, including specific departmental process improvement plans. Other duties as assigned.

Reports to Position Title: Manager, Special Investigation Unit

QUALIFICATIONS:
Education/Specialized Training/Licensure: High School diploma, GED, or equivalent; Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification required.

Bachelor's degree preferred.

Work Experience (Years and Area): 6-8 years of recent coding experience (in lieu of bachelor's degree) required.

Experience with a health plan or Third-Party Administrator preferred

Management Experience (Years and Area): N/A

Software Proficiencies: Microsoft Office (Word, Excel, Outlook)

Other: Strong critical thinking and analytical skills required.



Job Family/Job Title Competencies:
Problem Analysis
Analytical Thinking
Attention to Detail
Results Oriented
Above Average Verbal
Writing /Composing
Medical Terminology


INTERPERSONAL SKILLS
Excellent interpersonal, written and verbal communication skills required. Ability to maintain strict confidentiality.