Lead Coding Analyst (RN or LPN) - Remote

Summary of Position

• Direct the standard for code review functions in the setting of authorizations, claims review, grievance and appeal, and new medical policy implementation.  
   
• Ensure the quality and productivity of appeals and work queues of coders. 
   
• Develop and design proposed coding review functions for insourcing current vendor prepay and post payment coding reviews.  
   
• Manage EmblemHealth responses to audits and inquiries by external agencies. 
   
• Support analyses for the Special Investigations Unit and Legal Department.

Principal Accountabilities 

• Develop and implement changes for insourcing coding reviews from vendors. 
   
• Design plans and processes to ensure clinical documentation supports coding and billing. 
   
• Develop and maintain analytics and payment integrity savings reports regarding clinical documentation reviews. 
   
• Represent departmental positions at meetings of, and correspondence with, the Reimbursement Policy Committee.  
• Analyze and report outcomes measures for coding changes by external vendors.  
   
• Provide the internal responses to complex problems including legal issues, special investigations, claims denials by provider groups.  
   
• Review claims, ensure accurate charge capture and review medical necessity for coders.  
   
• Develop guidelines for coding and documentation to ensure physician and hospital compliance.  
   
• Act as a clinical coding liaison between the utilization management, medical directors, and coding functions.  
   
• Serve as a resource for coding function in the Medical Utilizations Review Unit to ensure proper level of coding and payment of medical claims as a subject matter expert. 
   
• Collaborate with clinical administration on coding and reimbursement implications of care management programs.  
• Manage a partial caseload of claims reviews.  
   
• Ensure prompt and accurate responses to all internal partners.  
   
• Maintain productivity and quality measures for the coding review function within the department.  
   
• Demonstrate expertise in ICD-10-CM/PCS coding to act as a resource for the education of provider, nursing, and healthcare staff, as well as new employees.  
   
• Present findings to senior management and external parties. 
   
• Train staff as they enter the department in all areas of coding and analysis.  
   
• Research, review, and analyze new medical procedures, technology, equipment, and corresponding CPT/HCPCS (Healthcare Common Procedure Coding System) codes; gather input from providers; recommend coverage and reimbursement levels consistent with state and federal policies.