Program Integrity Coding & Research Analyst (Health Plan Experienced)

Job Summary:

The Program Integrity Coding & Research Analyst acts as a Medical Coding subject matter expert for complex coding concerns and serve as primary coding resource for Program Integrity (PI).

• Essential Functions:
• •Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions

Take a lead role to determine root cause of provider claim issues and resolve by analyzing system configuration, payment policy, and claims data

Oversight of quality audit programs for internal coding validation analysts and produce monthly reports for the managers

Researchpolicy impacts and communicate those impacts based on audit type and risk to the business

Assist in the development and implementation of an annual audit plan for providers with high risk for fraud using appropriate risk-based methodology

Act as subject matter expert for claim accuracy audits for all steps in the audit lifecycle, including disputes

Lead automation requirements for AI auditing workflows, including QA of policy summaries, checklists and other reference materials used in audits and investigations

Collaborate in maintaining effective internal training processes

Serve as primary contact for state and market escalations by providers

Participate in the preparation of legal activities which includes discovery and trial preparation and testifying as needed

Build strong working relationships with Markets and departments that are essential for resolving systemic issues and driving process improvements

Provide critical research and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements

Recognize inconsistencies and gaps in audit capabilities and processes and work collaboratively to resolve the identified issues

Identify, document, and report on issues with claims reimbursement methodologies

Support the entry and tracking of system change requests, via appropriate ticketing system, for configuration or other Program and Payment Integrity improvements, act as primary resource and SME in corporate meetings and projects

• •Analyze and report measurable changes in efficiency or financial savings related to process improvements
• •Perform any other job related duties as requested.

• Education and Experience:
• •Bachelor's degree in Business Administration or related field required
• •Equivalent years of relevant work experience may be accepted in lieu of required education
• •Seven (7) years of experience in medical coding, to include experience in program integrity coding audit required

Five (5) years of experience working with Medicaid policy in developing, analyzing and consulting preferred

Experience using AI tools and processes preferred

Experience with reimbursement methodology (APC, DRG, OPPS) required

• Competencies, Knowledge and Skills:
• •Proficient in Microsoft Office toolset

Proven ability to establish effective working relationships with stakeholders at all different levels

Excellent written and verbal communication skills

Effective identification of business problems, assessment of proposed solutions to those problems, and understanding of the needs of stakeholders

Ability to work independently and within a team environment

Ability to multi-task and prioritize work to meet project deadlines

Effective listening and critical thinking skills

Flexibility during organizational and/or business changes

Strong interpersonal and relationship building skills

Effective problem-solving skills with attention to detail

Ability to effectively and efficiently lead and/or work within a project team

Time management skills

Customer service oriented

Decision making/problem solving skills

Ability to develop, prioritize and accomplish goals

Ability to coordinate and lead cross-functional teams

• Licensure and Certification:
• •Certified Professional Coder (CPC) or equivalent billing/coding designation required

• Working Conditions:
• •General office environment; may be required to sit or stand for extended periods of time
• •Travel is not typically required

Compensation Range:

$72,200.00 - $115,500.00 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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Brand=CareSource