Lead Medical Coding Specialist
We are seeking an accomplished individual to collaborate at a high level with senior managers and stakeholders to develop solutions and influence decisions that drive progress on health care issues that impact all Washingtonians.
This is a dynamic role that will utilize both your expertise and ability to connect and communicate with people, as well as your foundation of technical experience and skills.
The ideal candidate for this position will have at least five years of professional coding audit experience working at a State Medicaid Agency, health care plan, hospital, health clinic or facility and a Bachelor’s Degree in a healthcare related field.
If you are interested in doing fun and meaningful work with an energetic team of collaborators and decision makers, we want to talk with you!
Position Objective:
The Division of Program Integrity’s (PI’s) mission is to identify and prevent improper payments resulting from fraud, waste and abuse. The Lead Medical Coding Specialist (MPS 3) reports to the Program Integrity Clinical Review Unit Manager, and plays an important role in ensuring HCA is an effective steward of federal and state resources by providing reasonable and consistent oversight of the HCA’s Medical Assistance programs.
This position is a subject matter expert who leads other medical coders within the Clinical Review Unit, provides expert-level consultation to HCA staff, develop and facilitate ongoing medical coding training, performs professional work conducting statewide regulatory analysis and medical coding reviews, examinations, and other program integrity activities of both fee for service (FFS) and HCA-contracted Managed Care Entity (MCE) reported encounters. This position may participate in fraud and abuse investigations.
Some of what you will do:
• Plan, design, lead audits of complex, risk-focused or statistical sampling of both fee-for-service and managed care encounter data; medical claims case selection;
• Utilize available data analytic tools to identify aberrancies in provider billing in relation to diagnosis code, procedure code and/or DRG assignments.
• Oversee the work of staff who perform coding compliance audit reviews;
• Conduct internal control measures of medical coding audits – review for accuracy and quality;
• Review and approve medical coding audit findings prior to provider notification of audit results.
• Develop, update, maintain, and teach staff on the fundamentals of diagnosis and procedural (ICD-9, ICD-10, CPT, HCPCS) coding;
• Facilitate training in classroom, remote setting, or recorded environment;
• Track and coordinate continuous education opportunities for Program Integrity staff.
• Interpret and apply the complexities of national coding rules, relevant federal, state and HCA laws, regulations, policies and managed care contract requirements;
• Take prompt corrective action and mandatory regulatory action when adverse findings are identified;
• Prepare preliminary and final audit reports, documenting adverse findings, concerns, corrective actions, recommendations, and directives;
• Respond to disputes and appeals of coding audit adverse findings;
• Provide testimony in administrative hearings to defend coding audit adverse findings;
• Provide consultative services to internal Agency staff and medical providers regarding the interpretation of medical coding and procedural guidelines;
• Assist Section fraud investigators with interpretation of medical coding terms and application, in relation to managed care encounter data;
• Conduct interviews with key provider and entity staff;
• Meet with affected parties regarding concerns identified with MCE financial expenditures related to coding audit findings;
• Provide provider education throughout the audit process and as needed, participates in educational visits, meetings, teleconferences, presentations and/or webinars.
• Provide education and technical assistance to MCEs.
• Participate in the writing or revision of publications such as Washington Apple Health Provider Guides and WAC.
• Provide technical assistance to ProviderOne team by evaluating payment system edits as they pertain to audit and review findings to determine and recommend the creation of new or refinement of existing edits.
Here is what we are looking for (Required Qualifications):
A Bachelor’s Degree in a healthcare related field with a minimum of five years of professional coding audit experience working at a State Medicaid Agency, health care plan, hospital, health clinic or facility, etc.
OR
An Associate’s degree in a healthcare related field with a minimum of seven years of professional coding audit experience working at a State Medicaid Agency, health care plan, hospital, health clinic or facility, etc.
OR
One year of experience as a Medical Program Specialist 2.
OR
Two years of experience as a Medical Program Specialist 1.
AND
• Active credential as a certified medical coder under the American Health Information Management Association (AHIMA)– Registered Health Information Administration (RHIA) – Registered Health Information Technology (RHIT) – Certified Coding Specialist (CCS) or Certified Coding Specialist – Physician-based (CCS-P) or the American Academy of Professional Coders (AAPC) – Certified Profession Coder (CPC)
• Knowledge of national ICD-10, CPT, HCPCS coding systems and rules
• Ability to apply coding knowledge and logic in the evaluation and examination of hospital FFS claims managed care encounters
• Knowledge of processing diagnosis, procedure and medical service codes for payment
• Experience with federal provider preventable condition payment rules
• Strong data analytic skills with ability to recognize aberrant provider billing in claim and encounter data
• Understand the importance of examining financial expenditures
• High degree of initiative, self-starter, goal-oriented, and ability to motivate individuals to achieve targeted results
• Excellent communications skills with ability to communicate effectively across multiple levels of the organization and with program customers and stakeholders
• Strong planning and organizational skills
• Strong Microsoft Office skills (Project, Word, Excel, PowerPoint, Outlook)
• Effective time and project management skills with the ability to develop and advance assigned projects from inception to completion.
• Ability to exercise professional independent judgment and reach sound decisions.
• Ability to contribute effectively in a team and participate in making team decisions.
• Ability to lead teams and build consensus.
• Ability to work effectively in an adversarial environment.
Desirable/Preferred Qualifications:
• Knowledge of federal Medicaid regulations
• Knowledge of program integrity principles
• Knowledge of current and developing trends in medical healthcare delivery systems and billing.
• Knowledge of Health Insurance Portability and Accountability Act and Personal Health Information privacy rules, regulations, and policies.
Knowledge of medical coding course development and facilitation