Profile
We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only).
Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.
Veterans, Reservists, Guardsmen and military family members are encouraged to apply!
Job Summary
Under the direction of the DRG Supervisor or designee, conducts retrospective medical claims review for coding and pricing determinations and/or coding review for inpatient (facility) claims to include diagnosis and procedural coding with DRG assignment. Subject matter expert on medical claims coding for outpatient and inpatient services. Provides coding-related information to medical directors, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management and the claims subcontractor as needed. Functions as the designated recipient for factual network provider claim review requests. Develops determination letters. Provides support to non-clinical and clinical staff on coding and retrospective medical claims review processes.
Education & Experience
Required:
- High School Diploma or GED
- Current certification as Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), or Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Professional Coder.
- U.S. Citizen
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- Minimum 5 years of clinical coding experience for facility and/or professional accounts
- Minimum 3 years of claims processing experience for inpatient and/or outpatient accounts
- Documented experience in a fast-paced environment
Preferred
- Experience in the private medical industry, health insurance or Managed Care field
- Familiarity with TRICARE and the military healthcare delivery system
Key Responsibilities
- Serves as the subject matter expert and resource on ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding of medical claims.
- Takes the lead role for coding projects as directed by Clinical Operations management.
- Provides training and mentoring for new and existing Clinical Coders.
- Performs medical claims coding reviews using current coding guidelines.
- Performs focused outpatient and/or inpatient claims reviews as requested by management and summarizes findings.
- Identifies and reports potential fraudulent or quality issues.
- Acts as a resource for TriWest staff on ICD-10-CM, ICD-10-PCS, CPT and HCPCS coding.
- Researches TRICARE manuals for benefits, limitations and exclusions, current coding guidelines to assist with the Referral and Authorization Decision Support tool process.
- Monitors and tracks timeliness of retrospective claims reviews response to ensure compliance with required timelines for completion of assigned reviews.
- Prepares determination notices and other written correspondence.
- Identifies questionable review decisions and forwards to the appropriate Medical Director for evaluation and/or corrective action.
- Provides accurate data entry in the medical management and claims system.
- Reviews coding issues identified by the TRICARE Quality Monitoring Contractor (TQMC) & documents findings, rationale, and corrective actions.
- Performs other duties as assigned.
- Regular and reliable attendance is required.
Competencies
Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.
Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.
Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.
Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.
Technical Skills: Advanced knowledge of ICD-10-CM, ICD-10 PCS HCPCS and CPT coding; advanced knowledge of utilization review processes and/or claims processing; ability to maintain the confidentiality and security requirements of medical records; proficient with Word and Excel; ability to meet department performance standards.
Working Conditions
Working Conditions
- Availability to work any shift
- Ability to work independently from home (Remote)
- Extensive computer work with prolonged sitting
Company Overview
Taking Care of Our Nation’s Heroes.
It’s Who We Are. It’s What We Do.
Do you have a passion for serving those who served?
Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve®!
Our job is to make sure that America’s heroes get connected to health care in the community.
At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.
DoD Statement
Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.
Benefits
We’re more than just a health care company. We’re passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:
- Medical, Dental and Vision Coverage
- Generous paid time off
- 401(k) Retirement Savings Plan (with matching)
- Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
- Tuition reimbursement
- Paid volunteer time
*Annual base salary for Colorado, Hawaii, Washington D.C. and Washington State residents: $73,000- $94,000 depending on experience*
Equal Employment Opportunity
TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.
