Note: The job is a remote job and is open to candidates in USA. EmblemHealth is hiring a Lead Coding Analyst to direct coding review standards across authorizations, claims, appeals, and medical policy implementation. The role oversees coding quality and productivity, develops coding review and payment-integrity processes, manages responses to external audits, and supports investigations and legal analyses.

Responsibilities

• Develop and implement changes for insourcing coding reviews from vendors
• Design plans and processes to ensure clinical documentation supports coding and billing
• Develop and maintain analytics and payment integrity savings reports regarding clinical documentation reviews
• Represent departmental positions at meetings of, and correspondence with, the Reimbursement Policy Committee
• Analyze and report outcomes measures for coding changes by external vendors
• Provide the internal responses to complex problems including legal issues, special investigations, claims denials by provider groups
• Review claims, ensure accurate charge capture and review medical necessity for coders
• Develop guidelines for coding and documentation to ensure physician and hospital compliance
• Act as a clinical coding liaison between the utilization management, medical directors, and coding functions
• Serve as a resource for coding function in the Medical Utilizations Review Unit to ensure proper level of coding and payment of medical claims as a subject matter expert
• Collaborate with clinical administration on coding and reimbursement implications of care management programs
• Manage a partial caseload of claims reviews
• Ensure prompt and accurate responses to all internal partners
• Maintain productivity and quality measures for the coding review function within the department
• Demonstrate expertise in ICD-10-CM/PCS coding to act as a resource for the education of provider, nursing, and healthcare staff, as well as new employees
• Present findings to senior management and external parties
• Train staff as they enter the department in all areas of coding and analysis
• Research, review, and analyze new medical procedures, technology, equipment, and corresponding CPT/HCPCS (Healthcare Common Procedure Coding System) codes; gather input from providers; recommend coverage and reimbursement levels consistent with state and federal policies

Skills

• Bachelor's degree, preferably in a healthcare/business/quantitative science field of study
• Additional experience/specialized training may be considered in lieu of educational requirements
• CCS (AHIMA Certified Coding Specialist or CPC (AAPC Certified Professional Coder)
• Current and active RN or LPN license
• Clinical Documentation Reviewer certification (through AAPC or ADCIS
• 5 – 8+ years of relevant, professional work experience
• 5+ years of coding experience
• Strong analytic and organization abilities, along with effective presentation and collaboration skills
• Proficient with MS Office (Word, Excel, Access, PowerPoint, Outlook)
• Ability to manage multiple priorities
• Excellent verbal and written communication and interpersonal skills
• 1 year management or leadership experience in a healthcare environment

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