Program Integrity Coding & Research Analyst (Health Plan Experienced)

Job Summary:

The Program Integrity Coding & Research Analyst acts as a Medical Coding subject matter expert for complex coding concerns and serve as primary coding resource for Program Integrity (PI).

• Essential Functions: Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions
• Take a lead role to determine root cause of provider claim issues and resolve by analyzing system configuration, payment policy, and claims data
• Oversight of quality audit programs for internal coding validation analysts and produce monthly reports for the managers
• Researchpolicy impacts and communicate those impacts based on audit type and risk to the business
• Assist in the development and implementation of an annual audit plan for providers with high risk for fraud using appropriate risk-based methodology
• Act as subject matter expert for claim accuracy audits for all steps in the audit lifecycle, including disputes
• Lead automation requirements for AI auditing workflows, including QA of policy summaries, checklists and other reference materials used in audits and investigations
• Collaborate in maintaining effective internal training processes
• Serve as primary contact for state and market escalations by providers
• Participate in the preparation of legal activities which includes discovery and trial preparation and testifying as needed
• Build strong working relationships with Markets and departments that are essential for resolving systemic issues and driving process improvements
• Provide critical research and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
• Recognize inconsistencies and gaps in audit capabilities and processes and work collaboratively to resolve the identified issues
• Identify, document, and report on issues with claims reimbursement methodologies

Support the entry and tracking of system change requests, via appropriate ticketing system, for configuration or other Program and Payment Integrity improvements, act as primary resource and SME in corporate meetings and projects

Analyze and report measurable changes in efficiency or financial savings related to process improvements

Perform any other job related duties as requested.

• Education and Experience: Bachelor's degree in Business Administration or related field required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Seven (7) years of experience in medical coding, to include experience in program integrity coding audit required
• Five (5) years of experience working with Medicaid policy in developing, analyzing and consulting preferred
• Experience using AI tools and processes preferred
• Experience with reimbursement methodology (APC, DRG, OPPS) required
• Competencies, Knowledge and Skills: Proficient in Microsoft Office toolset
• Proven ability to establish effective working relationships with stakeholders at all different levels
• Excellent written and verbal communication skills
• Effective identification of business problems, assessment of proposed solutions to those problems, and understanding of the needs of stakeholders
• Ability to work independently and within a team environment
• Ability to multi-task and prioritize work to meet project deadlines
• Effective listening and critical thinking skills
• Flexibility during organizational and/or business changes
• Strong interpersonal and relationship building skills
• Effective problem-solving skills with attention to detail
• Ability to effectively and efficiently lead and/or work within a project team
• Time management skills
• Customer service oriented
• Decision making/problem solving skills
• Ability to develop, prioritize and accomplish goals
• Ability to coordinate and lead cross-functional teams
• Licensure and Certification: Certified Professional Coder (CPC) or equivalent billing/coding designation required
• Working Conditions: General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required