Job Overview
Location
Remote
Job Type
Full-time
Category
Software Engineering
Date Posted
April 4, 2026
Full Job Description
đź“‹ Description
- • The PI Medical Coding Reviewer III plays a critical role in ensuring accurate and compliant medical claim processing by generating in-depth reporting and analysis for Pre-Pay and Post-Paid processes, directly supporting CareSource’s program integrity and financial accuracy.
- • Day-to-day responsibilities include producing provider pre-pay production and progress reports, recommending process improvements, mentoring Claims Analysts, identifying knowledge gaps, coordinating training for new and existing staff, detecting workflow inefficiencies, and serving as the primary resource for the provider pre-pay team.
- • The role requires applying deep knowledge of CPT, ICD-10, HCPCS, DRG, and REV coding rules to analyze complex claims, interpreting state and federal Medicaid/Medicare regulations, and making payment decisions on complex claims while referring suspected fraud, waste, or abuse to the Special Investigations Unit.
- • Working within CareSource’s Program Integrity team, the reviewer collaborates cross-functionally with Claims, Configuration, Health Partners, and IT to address system gaps, uphold compliance standards, and drive continuous improvement in claims processing accuracy and efficiency.
- • This position offers the opportunity to develop leadership and mentoring skills, deepen expertise in healthcare reimbursement methodologies (APC, DRG, OPPS), and gain influence in shaping organizational processes while working with considerable autonomy under limited supervision.
🎯 Requirements
- • Certified Medical Coder credential (CPC, RHIT, or RHIA) required at time of hire
- • Minimum of five (5) years of medical billing and coding experience, including at least three (3) years of SIU/FWA-specific experience
- • Prior experience with claim pre-payment, medical claim and documentation auditing, and Medicaid/Medicare claims
- • Proficiency in Microsoft Office Suite and familiarity with Facets (3+ years preferred)
- • Knowledge of reimbursement methodologies (APC, DRG, OPPS) and inpatient coding (preferred)
- • Strong analytical, communication, and interpersonal skills with ability to work independently and in teams
🏖️ Benefits
- • Competitive salary range of $62,700.00 to $100,400.00 based on experience and qualifications
- • Eligibility for performance-based bonuses tied to company and individual performance
- • Access to a comprehensive total rewards package supporting employee well-being
- • Opportunity to work remotely with flexibility in work location
- • Professional development through mentoring, training coordination, and leadership responsibilities
- • Exposure to cross-functional collaboration with Claims, IT, Health Partners, and Configuration teams
Skills & Technologies
About CareSource Management Group Company
CareSource is a nonprofit, multi-state managed care organization headquartered in Dayton, Ohio. Founded in 1989, it administers Medicaid, Medicare Advantage, and Marketplace health plans serving over two million members in Ohio, Kentucky, Indiana, West Virginia, and Georgia. The company focuses on improving health outcomes for low-income and vulnerable populations through integrated care management, behavioral health services, and social determinants programs.
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