Homeoffice Sr, Medical Coding Specialist en Claritev
Claritev · Work From Home, Estados Unidos De América · Remote
- Senior
At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our purpose is simple - we strive to bend the cost curve in healthcare for all. Our dedication to service excellence extends to all our stakeholders -- internal and external - driving us to consistently exceed expectations. We are intentionally bold, we foster innovation, we nurture accountability, we champion diversity, and empower each other to illuminate our collective potential.
Be part of our amazing transformational journey as we optimize the opportunity towards becoming a leading technology, data, and innovation voice in healthcare. Onward and Upward!!!
JOB SUMMARY: The Senior Medical Coding Specialist provides analysis of the highest dollar and most complex claims by applying research, coding standards, industry knowledge and federal regulations to ensure correct billing practices. In this role, the incumbent will perform reviews to identify variations from quality billing practices and monitor bills for accuracy and compliance. This position also requires familiarity with international coding systems and healthcare billing practices to support global operations and ensure alignment with international standards.
JOB ROLES AND RESPONSIBILITIES:
1. Review and analyze complex inpatient, outpatient, and practitioner billing for medical appropriateness of treatment; analyze charges of various revenue centers with consideration to patient diagnosis, procedures, age and facility type and international healthcare norms where applicable
2. Assist management in the daily operations and processes within the department.
3. Design and participate in the clinical and coding education of coders, negotiators, and physicians, incorporating international coding systems (e.g., ICD-10-AM, OPCS-4, SNOMED CT). This includes orientation, training and mentoring of new and existing staff.
4. Facilitate daily claim completion meetings with coding operations teams, including international counterparts when applicable; discuss complex cases, provide feedback, and initiate new coding protocols.
5. Drive successful coding operations through the application of learned, certified knowledge in addition to continuous professional development and ongoing coding research.
6. Provide general support to clinical team members, serving as a resource and subject matter expert (SME).
7. Monitors turnaround times for multiple applications and provides suggestions for process efficiencies.
8. Uses independent decision making skills to review claims after business hours to meet deadlines.
9. Apply national and international coding standards and regulations to claims billed.
10. Research and review individual claims, claim trends or detailed itemized bills, operative notes and other documentation as needed.
11. Collaborate with physician and analytics teams to create, enhance or suggest new coding edits, claim factors, guidelines and other applicable reference materials.
12. Monitor, research, and summarize trends, coding practices, and regulatory changes.
13. Apply clinical judgment and high level of expertise along with analytic skills in review of the most challenging and difficult cases; including conducting additional research as needed.
14. Communicates clinical, coding and reimbursement findings to co-workers and management in a clear, organized manner.
15. Evaluate performance of both newly hired and existing staff. .
16. Assist with education of staff as it relates to claims, suggest additional negotiation talking points or tools, develop instructional design, when applicable and communicate overall industry or regulatory changes which affect the department.
17. Partner with management to drive department goals and objectives.
18. Collaborate, coordinate, and communicate across disciplines and departments, and international teams.
19. Ensure compliance with HIPAA regulations and international data protection regulations (e.g., GDPR, PIPEDA).
20. Demonstrate commitment to the Company's core values.
21. Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.
22. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.
2. Assist management in the daily operations and processes within the department.
3. Design and participate in the clinical and coding education of coders, negotiators, and physicians, incorporating international coding systems (e.g., ICD-10-AM, OPCS-4, SNOMED CT). This includes orientation, training and mentoring of new and existing staff.
4. Facilitate daily claim completion meetings with coding operations teams, including international counterparts when applicable; discuss complex cases, provide feedback, and initiate new coding protocols.
5. Drive successful coding operations through the application of learned, certified knowledge in addition to continuous professional development and ongoing coding research.
6. Provide general support to clinical team members, serving as a resource and subject matter expert (SME).
7. Monitors turnaround times for multiple applications and provides suggestions for process efficiencies.
8. Uses independent decision making skills to review claims after business hours to meet deadlines.
9. Apply national and international coding standards and regulations to claims billed.
10. Research and review individual claims, claim trends or detailed itemized bills, operative notes and other documentation as needed.
11. Collaborate with physician and analytics teams to create, enhance or suggest new coding edits, claim factors, guidelines and other applicable reference materials.
12. Monitor, research, and summarize trends, coding practices, and regulatory changes.
13. Apply clinical judgment and high level of expertise along with analytic skills in review of the most challenging and difficult cases; including conducting additional research as needed.
14. Communicates clinical, coding and reimbursement findings to co-workers and management in a clear, organized manner.
15. Evaluate performance of both newly hired and existing staff. .
16. Assist with education of staff as it relates to claims, suggest additional negotiation talking points or tools, develop instructional design, when applicable and communicate overall industry or regulatory changes which affect the department.
17. Partner with management to drive department goals and objectives.
18. Collaborate, coordinate, and communicate across disciplines and departments, and international teams.
19. Ensure compliance with HIPAA regulations and international data protection regulations (e.g., GDPR, PIPEDA).
20. Demonstrate commitment to the Company's core values.
21. Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.
22. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.
JOB SCOPE: This position works independently with minimal supervision in order to complete the outlined responsibilities. The incumbent balances several projects at a time and work is varied and complex. More complex issues are referred to higher levels. The incumbent follows established procedures and uses knowledge of the Company's general business principles, industry dynamics, market trends, and specific operational details when performing all aspects of the job.
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