Clinical Inpatient/Outpatient Coder

Position Overview:

Responsible for the codification and mapping of benefit product building, including the development and maintenance of the benefit configuration document and attaching appropriate service rules required for each benefit category. Serve as a subject matter expert in all areas of the medical plan configuration, medical utilization edits, service payment limits and service rules. Develop workflows and business processes to ensure timely and accurate system build. Act as a facilitator to accurately translate product benefit and all aspects of the service rules into a configurable document.

 The coder will provide business requirements to core configuration for purposes of translating clinical concepts into system configuration requirements. The coder will provide guidance to fellow employees and providers regarding documentation concerns as they relate to coding and billing.

Validates the ICD-9-CM / ICD-10-CM codes billed on the medical claim and DRG assignments appropriateness to ensure consistency and efficiency in inpatient claims processing, data collection, and quality reporting for the medical unit; report results, findings and recommendations to the supervisor, and assist with the development of process improvements to maintain data quality.

 Scope of Role & Responsibilities: 

  • Ensure timely and accurate document preparation and reference materials for team members for future reference of medical benefit configuration setup.
  • Oversee test load and configure business decisions into system.
  • Support quality reviews and testing of all benefit setup prior to implementation and go-live date.
  • Partner with Compliance department to audit setups and configure post go-live.
  • Resolve escalated and complex processing, change requests, issues or questions.
  • Responsible for own work flow assignments and must be able to take the initiative to resolve problems and meet deadlines.
  • Serve as a lead for team regarding any benefit and configuration issues or questions.

 Required Education, Training & Professional Experience: 

  • 3-5 years health care experience in a physician group practice or other ambulatory care setting preferred.
  • 1-year medical coding experience with demonstrated sustained coding quality.

 Licence and/or Certification Required:

  • Certification as a professional coder (CPC)

 Professional Competencies:

  •  Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication

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