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Senior Coding and Claims Auditor

Company: American Health Plans Inc.
Location: Franklin
Posted on: June 19, 2022

Job Description:

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, and Mississippi, with planned expansion into other states in 2021. For more information, visit AmHealthPlans.com. JOB SUMMARY:The Sr. Claims and Coding Auditor will be responsible for reviewing processed claims prior to payment release and for claim-based projects involving research and resolutions of discrepancies. Additionally, this role will be responsible for conducting coding audits prior to payment release. The Sr. Claims and Coding Auditor may also complete post-payment coding reviews and provider education.ESSENTIAL JOB DUTIES:To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation; including, but not limited to:

  • Review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify and ensure the accuracy, completeness, specificity and appropriateness of diagnosis codes based on services rendered
  • Conduct pre-pay and post-pay coding audits to ensure accurate claims' payments and denials.
  • Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of coding standards.
  • Follow all appropriate Federal and State regulatory requirements and guidelines applicable to Health Plan operations or as documented in company policies and procedures.
  • Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials
  • Assist with validation audits to evaluate medical record documentation to ensure coding accurately reflects and supports relevant coding based on the ICD-10 code submitted to CMS for reimbursement and interpretation of medical documentation to ensure capture of all relevant coding
  • Work directly with provider representatives and executive directors on Letters of Agreement (LOAs) to ensure appropriate coding methodology and reimbursement.
  • Participate in and support ad-hoc coding audits as needed.JOB REQUIREMENTS:
    • Extensive knowledge of ICD-10 diagnosis coding and auditing
    • Strong knowledge of CMS requirements regarding claims processing, especially regarding skilled nursing facilities and other complex claim processing rules and regulations
    • Knowledge of automated claims processing systemsREQUIRED QUALIFICATIONS:
      • Experience: Two (2) years' experience with complex claims processing and/or coding auditing experience in the health insurance industry or medical health care delivery system
      • Two (2) years' experience in managed healthcare environment related to claims processing/coding audits
      • 2 + years of experience in managed healthcare environment related to claims' and/or coding audits.
      • Two (2) years' experience with standard coding and reference materials used in a claim setting, such as CPT4,
      • ICD-10 and HCPCS
      • Two (2) years' experience with CMS requirements regarding claims processing; especially Skilled Nursing Facility and other complex claim processing rules and regulations
      • Two (2) years' experience processing/coding auditing claims for Medicare, Medicaid plans, or other health plan type
      • Two (2) years' experience coding and auditing claims for Medicare and Medicaid plans.
      • 2 year(s): Experience in managed healthcare and/or commercial environment related to coding audits
      • License/Certification: Coding certification required SUPERVISORY RESPONSIBILITES:
        • Does not have supervisory responsibilities
        • EQUAL OPPORTUNITY EMPLOYEROur Organization does not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. The Organization will also make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made.

Keywords: American Health Plans Inc., Franklin , Senior Coding and Claims Auditor, Accounting, Auditing , Franklin, Tennessee

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