Coding Integrity Auditor - Remote - Emblem Health

• Responsible for upholding the standard for code review functions in the setting of claims review, grievance and appeal, and
new medical policy implementation.
• Identify inconsistencies between CCI & EH reimbursement policies and claim which directly impact claim payment (i.e.
authorizations) and responsible for working with leadership to bring to resolution.
• Perform audit of suspended and appealed claims reviewed by coding staff.
• Perform audits of outlier providers for accurate coding practices and documentation requirements.

Principal Accountabilities

• Audit internal and external business partners (processes and results) for accurate claim coding reviews for various
programs, pre- and post-payment.
• Audit claim reviews and medical records to ensure accurate adjudication; review decisions from Coding Integrity team;
provide feedback, results, and recommendations to management.
• Review reporting for outlier provider claims; request patient medical records to assign diagnoses, treatments, and
surgical and non-surgical procedures for facility and medical services for coding and payment integrity.
• Provide direct education to the business and provider offices as needed to facilitate an understanding of correct claim
coding, use of CPT, ICD-10, HCPCS, etc.
• Perform audits of changes to coding introduced by new medical policies, reimbursement policies, regulatory changes,
and business requirements on a quarterly basis.
• Participate in RPC, RPCW, Medical Policy Committee (MPC) and Medical Policy Committee Workgroup (MPCW) as
added Coding Integrity representation at meetings; ensure that decisions are appropriate and will result in accurate
claim reimbursement.
• Identify reimbursement and coding variances from industry standards and brings to leader's attention.
• Provide support for internal and vendor edit reviews and provider contracts.
• Perform related tasks as directed or required.

Education, Training, Licenses, Certifications

• Bachelor's degree, preferably in a healthcare, quantitative/analytical, or business related field of study.
• AAPC CPC (AAPC Certified Professional Coder) &/or CCS (AHIMA Certified Coding Specialist)
• AAPC CPMA (AAPC Certified Professional Medical Auditor)

Relevant Work Experience, Knowledge, Skills, and Abilities

• 3 - 5+ years of coding experience. (R)
• 1+ year auditing experience. (R)
• Additional years of related work experience/specialized training may be considered in lieu of educational requirements. (R)
• Proficiency with MS Office (Word, Excel, Access, PowerPoint, Outlook, Teams, etc.) (R)
• Attention to detail; and ability to communicate or escalate issues in a timely manner. (R)
• Ability to independently prioritize and complete multiple tasks with competing priority levels and deadlines. (R)
• Ability to perform effectively in a fast-paced work environment. (R)
• Excellent communication skills (verbal, written, presentation, interpersonal) with all types and levels of audiences. (R)

Additional Information

• Requisition ID: 1000000634
• Hiring Range: $65,000-$75,000