Senior Clinical Coder

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We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, , 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 U.S. citizenship and a favorably adjudicated DOD background investigation for this position.

Veteran, Military Spouse or Military Affiliated are encouraged to apply!

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 (DRG Validation.) 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.

• High School Diploma or GED
• Current certification as Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), or Registered Health Information Technician (RHIT).
• 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

• Experience in the private medical industry, health insurance or Managed Care field
• Familiarity with TRICARE and the military healthcare delivery system

• 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 DRG Validation of medical claims coding using current coding guidelines and support software.
• 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 Tri West 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.

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, Tri West 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 on inpatient facility coding and DRG validation; advanced knowledge of utilization review…