Program Integrity Coding & Research Analyst

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…