Responsibilities
- Support the design and implementation of clinical protocols, SOPs, and medical policies to guide the effective and accurate application of benefits.
- Analyze medical records and plan design language to ensure accurate code assignments (ICD, CPT, HCPC) and maintain compliance with federal and state regulations, applying independent judgment in coding interpretation and compliance decisions.
- Evaluate treatment plans, utilization management strategies, and prior authorizations while auditing large claims and itemized bills to identify discrepancies and recommend corrective actions.
- Partner with underwriting and stop-loss teams by providing coding insights to assess risk profiles and evaluate potential financial exposure related to medical treatments.
- Support clinical operations in the management, analysis, and oversight of clinical program data.
- Act as a trusted advisor across the organization, providing guidance and training materials to internal staff regarding coding practices and clinical standards.
Requirements
- Successful completion of a medical coding certification program.
- Bachelor’s degree in Nursing, Health Information Management, or a related education.
- 5+ years of medical coding experience and 2+ years in a health plan, TPA, or managed care organization.
- Expert knowledge of anatomy, medical terminology, and coding systems, including experience with coding software and EHRs.
- Demonstrated ability to analyze data, identify trends, and support decision-making related to fraud, waste, and abuse, with the ability to exercise independent judgment.
Nice to Have
- Previous experience at a high growth company.
Additional Information
- Generous PTO
- Up to 16 weeks paid parental leave
- Paid holidays
- 401k program
- Transportation perks
- Education reimbursement
- Paid paw-ternity leave
- Alternative medicine coverage
