Sr. Coding Integrity Auditor; Remote

Sr. Coding Integrity Auditor (Remote)

Joining Emblem Health as a Senior Coding Integrity Auditor (Remote), you will uphold coding review functions in the setting of business, industry, and legislative issues that impact quality coding audit and compliance. Your role involves identifying inconsistencies and coding compliance risks between EM Reimbursement policies and claims, auditing inpatient and outpatient medical records, and ensuring medical documentation supports billed conditions and DRGs.

• Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment.
• Review reporting for outlier provider claims; request patient medical records to assign diagnoses, treatments, and surgical and non-surgical procedures for facility and medical services for coding and payment integrity.
• Analyze and audit claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
• Identify potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
• Provide audit reporting, results, and recommendations to management and SIU as appropriate.
• Analyze results to assess compliance with regulations, identify procedural weaknesses and education needs that contribute to instances for non‑compliance both to business, external business partners, and providers.
• Prepare formal written reports summarizing current state (findings), desired future state, and critical success factors.
• Perform audits of changes to coding introduced by new medical policies, reimbursement policies, regulatory changes, and business requirements on a quarterly basis.
• Participate in RPC, RPCW, Medical Policy Committee (MPC) and Medical Policy Committee Workgroup (MPCW) as added Coding Integrity representation at meetings; ensure that decisions are appropriate and will result in accurate.
• Claim reimbursement.
• Identify reimbursement and coding variances from industry standards and bring to leader’s attention.
• Continuously gain knowledge of CPT, ICD, HCPCS and business/industry/legislative issues relating to and impacting quality coding audit and compliance issues.
• Perform related tasks as directed or required.

• Bachelor’s degree, preferably in a healthcare, quantitative/analytical, or business‑related field of study.
• AAPC CPC (AAPC Certified Professional Coder) & AAPC CIC (Certified Inpatient Coder) or CCS (AHIMA Certified Coding Specialist).
• AAPC CPMA (AAPC Certified Professional Medical Auditor).
• 4–6+ years of coding experience.
• 1+ year auditing experience.
• Extensive knowledge of inpatient DRG clinical documentation review.
• Additional related work experience/specialized training may be considered in lieu of educational requirements.
• Proficiency with MS Office (Word, Excel, Access, PowerPoint, Outlook, Teams, etc.).
• Attention to detail and ability to communicate or escalate issues in a timely manner.
• Ability to independently prioritize and complete multiple tasks with competing priority levels and deadlines.
• Ability to perform effectively in a fast‑paced work environment.
• Excellent communication skills (verbal, written, presentation, interpersonal) with all types and levels of audiences.

• Requisition :
• Hiring Range: $68,040–$118,800