Job Description
Serve as the SME for ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding
Perform DRG validation and retrospective medical claims reviews
Analyze inpatient and outpatient claims for coding accuracy and pricing determinations
Prepare determination letters and written review outcomes
Identify potential fraud, quality concerns, and coding discrepancies
Provide training and mentorship to clinical coding staff
Support cross-functional teams with coding guidance and review findings
Research medical policy, benefits, limitations, and current coding guidelines
Ensure timely completion of reviews in accordance with performance standards
Maintain accurate documentation within medical management and claims systems
Escalate complex cases to the Medical Director when appropriate
What you must have...