Job Description

Job Summary The Program Integrity Medical Coding Reviewer II is responsible for reviewing medical record audit activities, dispute support as needed, medical records work queues, and claim reviews for provider pre‑payment and post‑payment functions. Essential Functions Make medical records audit payment decisions on a wide variety of claim complexities within department standards. Research, analyze, and make audit payment decisions on moderately complicated claims based on medical coding guidelines and policies. Refer suspected Fraud, Waste, or Abuse to the SIU when identified in the normal course of business. Meet productivity standards while maintaining quality as outlined in SOP. Identify and implement process improvements and refer system enhancement ideas to management. Collaborate with internal departments to facilitate claim processing and reach appropriate claim resolutions. Respond to simple escalations and provider inquiries. Prepare claim audit summaries for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached. Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims. Identify systemic and process issues, problems, or concerns and report them to management. Back up administrative duties in medical record acquisition processes. Identify training and quality areas to be shared with management. Perform any other job‑related duties as requested. Education and Experience Associate’s degree required (Equivalent years of relevant work experience may be accepted). Three (3) years of medical billing coding experience. Medicaid/Medicare experience preferred. Clinical background with a firm understanding of claims payment preferred. Experience with reimbursement methodology (APC, DRG, OPPS) preferred. Competencies, Knowledge and Skills Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and physiology; Medicaid/Medicare reimbursement guidelines. Proficient in Microsoft Office Suite. General knowledge of healthcare claim payment processing. Familiarity with Facets Healthcare claim system configuration or experience is preferred. Experience reviewing medical records for proper medical coding. Excellent written and verbal communication skills. Ability to work independently and within a team environment. Effective problem‑solving skills with attention to detail. Knowledge of Medicaid/Medicare and familiarity with the healthcare industry. Effective listening and critical thinking skills. Ability to develop, prioritize, and accomplish goals. Strong interpersonal skills and a high level of professionalism. Licensure and Certification Certified Medical Coder (CPC, RHIT, or RHIA) is required at time of hire. Working Conditions General office environment; may be required to sit or stand for extended periods of time. Travel is not typically required. Compensation Range $54,500.00 – $87,300.00 Benefits Base compensation plus potential bonus tied to company and individual performance. Comprehensive total rewards package is offered. Equal Opportunity Employer CareSource is an Equal Opportunity Employer. Job Description Statement This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. #J-18808-Ljbffr CareSource

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