PI Medical Coding Reviewer I (CPC, RHIT or RHIA required)

📋 Description

• • Responsible for ensuring accurate and timely medical records requests are sent and received as part of pre-payment and post-payment claim review processes.
• • Process incoming medical records and assign them to appropriate claims and administrative queues for review.
• • Perform administrative tasks supporting audit functions, including error exception reporting, claims releases, and letter monitoring.
• • Support administrative deliverables for Prepay/Postpay email box requests, ensuring timely and accurate response to inquiries.
• • Make claim payment audit decisions on claims billed with uncomplicated medical codes, adhering strictly to departmental standards and coding guidelines.
• • Research and analyze medical claims based on CPT coding guidelines, diagnosis codes, medical terminology, anatomy and physiology, and Medicaid/Medicare reimbursement policies to determine appropriate payment decisions.
• • Identify and refer suspected cases of Fraud, Waste, or Abuse to the Special Investigations Unit (SIU) during routine claim reviews.
• • Identify opportunities for process improvements and recommend system enhancement ideas to management.
• • Ensure full adherence to company and departmental policies regarding timeliness of claim reviews and releases.
• • Report claim problems, anomalies, or concerns to management in a timely manner.
• • Maintain proficiency in Microsoft Office Suite for documentation, reporting, and communication tasks.
• • Review medical records to validate coding accuracy and compliance with billing and reimbursement standards.
• • Apply understanding of basic medical billing processes and claims payment principles to support audit and payment decisions.
• • Collaborate within a team environment while also working independently to meet deadlines and quality standards.
• • Demonstrate strong attention to detail, effective problem-solving skills, and critical thinking in evaluating complex medical claims.
• • Maintain effective written and verbal communication skills to interact with internal teams and document findings accurately.
• • Develop, prioritize, and accomplish daily goals aligned with departmental objectives and performance metrics.
• • Uphold high levels of professionalism and interpersonal skills in all workplace interactions.
• • Stay current with Medicaid/Medicare guidelines and healthcare industry standards to ensure accurate claim evaluations.
• • Perform any other job-related duties as assigned by management.