Responsible for ensuring professional handling of all member and provider reconsiderations in a timely and efficient way.
Responsibilities
Receives and performs initial research on member and provider reconsiderations
Categorizes each reconsideration appropriately
Completes data entry and documentation requirements in multiple systems
Acts as a liaison and coordinates functions with internal departments relative to the status of a member or provider reconsideration and the research needed to prepare the case for review
Prepares and presents cases to the Director of Claims and any appropriate committees
The Senior Coding Compliance Auditor will assist with the development and execution of the Annual Compliance Workplan including the Auditing and Monitoring Workplans. They will lead & complete detailed Coding compliance audits including complex audits, implement Management Action Plans, prepare high quality audit reports, establish and maintains an Audit the Auditor Quality program, coaches and mentors new and existing Coding auditors, and participate in other compliance program related activities.
Compensation
This position pays between $76,300 - $131,550 based on experience
Responsibilities
Conduct detailed coding auditing and monitoring activities on acute side
Analyze audit findings to identify discrepancies, trends, patterns which may lead to potential non-compliance and develop well thought actionable recommendations to mitigate associated risks
Create and maintain an Audit the Auditor program to monitor quality and identify opportunities for improvement related to audit management tools as well as audit processes
Provide regular updates to the Compliance leader on audits, MAPs outcomes, and escalate potential compliance concerns
Create and maintain training material for Audit process and how to use the Audit Management tool/platform
Requirements
Bachelors degree or equivalent experience, Health Records Management/Medical Coding
The Senior Coding Compliance Auditor will assist with the development and execution of the Annual Compliance Workplan including the Auditing and Monitoring Workplans. They will lead & complete detailed Coding compliance audits including complex audits, implement Management Action Plans, prepare high quality audit reports, establish and maintains an Audit the Auditor Quality program, coaches and mentors new and existing Coding auditors, and participate in other compliance program related activities.
Compensation
This position pays between $76,300 - $131,550 based on experience
Responsibilities
Conduct detailed coding auditing and monitoring activities on acute side
Analyze audit findings to identify discrepancies, trends, patterns which may lead to potential non-compliance and develop well thought actionable recommendations to mitigate associated risks
Create and maintain an Audit the Auditor program to monitor quality and identify opportunities for improvement related to audit management tools as well as audit processes
Provide regular updates to the Compliance leader on audits, MAPs outcomes, and escalate potential compliance concerns
Create and maintain training material for Audit process and how to use the Audit Management tool/platform
Requirements
Bachelors degree or equivalent experience, Health Records Management/Medical Coding
Provide thorough analysis and investigation of authorization requests for specialized medical/surgical/outpatient procedures, ensuring accurate and timely service to providers, hospitals, PCGs, and members.
Responsibilities
Analyze and investigate medical service authorization requests
Authorize select services that do not require clinical judgment
Collect and record data to issue authorizations
Route requests requiring medical review to appropriate team members
Facilitate communication with providers regarding status on authorizations and referrals
Requirements
Associate's degree in health care administration or other health related field
Two years full-time college credits
Nice to have: Current Michigan licensed LPN
Nice to have: RHIT (Registered Health Information Technician)
Nice to have: Certified Medical Assistant designation
Responsible for accurate claim submission, insurance follow-up, payment posting, denial resolution, and maintaining timely reimbursement for services provided.
Responsibilities
Review and accurately code OB/GYN encounters using ICD-10-CM, CPT, and HCPCS codes
Process and submit clean claims to commercial insurance, Medicare, and Medicaid
Ensure proper billing for prenatal care, deliveries, postpartum visits, gynecological procedures, ultrasounds, and office visits
Understand global maternity billing, including antepartum, delivery, and postpartum services
Review provider documentation to ensure coding accuracy and compliance
Requirements
Minimum 2 years of medical billing and coding experience
The Jr. Medical Billing Lead owns the financial performance, claim quality, and client relationships for an assigned portfolio of medical billing clients.
Responsibilities
Own collections performance for the assigned client portfolio, including underpayments and appeals
Work aged A/R based on revenue impact, prioritizing high-dollar balances and accounts at risk of timely filing
Identify revenue leakage from missed charges, underpayments, and payer contract variances
Escalate contract-level issues to the National Billing Manager
Review payment posting and adjustment accuracy for assigned accounts
Requirements
Bachelor’s degree in Accounting, Finance, Healthcare Administration, or a related field, or equivalent medical billing experience
OP Coder 3 will competently assign ICD-10-CM, CPT-4, HCPCS codes to more complex outpatient accounts for billing, internal and external reporting, research, and regulatory compliance.
Compensation
An individual's pay rate within the posted range may be determined by various factors, including skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization prioritizes pay equity and considers internal team equity when making any offer. Hiring at the maximum of the range is not typical. If your role is eligible for a sign-on bonus, the bonus program that is approved and in place at the time of offer, is what will be honored.
Responsibilities
Maintains knowledge of, and complies with, all relevant laws, regulations, policies, procedures and standards.
Actively participates in creating and implementing workflow improvements.
Assigns ICD-10-CM, CPT-4, or HCPCS codes to all diagnoses, treatments, and procedures on complex hospital outpatient or clinical department visits.
Knowledge of relationship of disease management, medications and ancillary test results on diagnoses assigned.
Is able to research and understand simple and moderately complex coding issues.
Requirements
Completion of an accredited coding certificate program
Responsible for accurate ICD-10-CM, CPT, and HCPCS coding for medical services in correctional healthcare facilities, ensuring compliance with Medicaid requirements and maintaining coding accuracy.
Responsibilities
Review provider documentation and assign accurate ICD-10-CM, CPT, and HCPCS Level II codes and modifiers for outpatient professional encounters
Maintain close working relationship with departmental staff and query providers and clinical staff when documentation is incomplete or conflicting
Work with billing team to resolve coding-related denials and rejections; identify trends and recommend corrective actions
Maintain current knowledge of state Medicaid fee schedules, billing manuals, demonstration special terms and conditions, National Correct Coding Initiative edits, and medically unlikely edits
Participate in internal coding audits and maintain a coding accuracy rate of 95 percent
Requirements
High school diploma or equivalent
Formal coding education covering medical terminology, anatomy and physiology, and pharmacology
Nice to have: Correctional healthcare coding experience
Nice to have: Behavioral health coding experience
Nice to have: Substance use disorder coding experience
A senior level Compliance Examiner and Analyst who works with the Compliance Officers to examine and analyze fraud, waste and abuse, compliance, and privacy related activities.
Responsibilities
Examine and analyze fraud, waste and abuse, compliance, and privacy related activities
Assess compliance with CPT, ICD-9/10, HCPCS, Payor guidelines, CMS guidelines, state and federal guidelines, cash controls, and TGC policies
Analyze internal and external risks and develop a Work Plan to detect, audit, analyze and report findings to Compliance officers and leadership partners
Develop and provide guidance to improvement teams related to improving conditions that may have caused errors
Conduct concurrent, prospective, and retrospective audits of medical record documentation, billing activity, provider activity, service lines, department processes, financials, contracts, assets, licensure/certification, etc.
Requirements
CPC (Certified Professional coder) required
LPN or CPMA preferred
Certifications from AHIMA (RHIA, RHIT, or CCS) or AAPC considered
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