Certified Coding Specialist

Cal Optima Health is seeking a highly motivated Certified Coding Specialist to join our team. The Certified Coding Specialist will assist the Manager Coding Quality in implementing coding standards for the organization, including researching relevant regulations, serving as a resource for other departments, and reviewing and recommending changes to systems, policies, or procedures to ensure current and appropriate coding guidelines are maintained.

The incumbent will review the appropriateness of codes billed when reviewing medical records related to provider disputes and appeals. Additionally, the incumbent will respond to questions submitted to the coding support mailbox and provide code guidance based on Medicare, Medi-Cal and national standards of billing protocol.

• Department:
  Coding Initiatives
• Salary Grade: 306 - $58,205 - $90,217 ($27.98 - $43.3736)
• Work Arrangement:
  Full Telework
• This position is eligible for telework in California.

• Program Support (approximately 95%)
  • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
  • Supports the manager in ensuring current coding methodology and modifier rules are applied to appropriate reimbursement and ensures the organization is following Medicare and Medi-Cal protocol for payment of claims.
  • Maintains and monitors code listing updates for ICD-10-CM/PCS, CPT and HCPCS as needed for all lines of business.
  • Assists the manager with identifying questionable billing practices based on coding protocol.
  • Responds with advice and instructions to any inquiries related to coding appropriateness and review of documentation provided.
  • Assists the Contracting department with contractual billing requirements based on coding standards by identifying applicable procedure codes according to provider specialty.
  • Presents at provider workshops and assists with provider training on regulations for appropriate coding of medical charts and documentation required to support proper claims submission.
  • Assists other departments regarding evaluation of medical records, procedures or diagnosis code questions; identifies ambiguous or non-specific medical documentation regarding coding protocols related to provider disputes, appeals and coding audits on submitted claims.
  • Stays current on official health care regulations, including reimbursement and documentation requirements related to professional claims billing. Ensures compliance with the standards of ethical coding as set forth by AHIMA and adheres to official guidelines.
• Other (5%)
  • Completes other projects and duties as assigned.

• Bachelor's degree in public health, health services or related field plus 3 years of coding experience with an emphasis on Medicare and Medi-Cal requirements in a managed care environment required; an equivalent combination of education and experience may qualify.
• 1 year of experience working with ICD-10-CM/PCS, CPT and HCPCS coding, medical terminology, human anatomy/physiology and regulatory requirements required.

• Experience working with MS-DRG, APR-DRG and Medi-Cal coding assignments as well as Medi-Cal chart auditing.

• Current Certified Coding Specialist (CCS), Certified Coding Specialist Physician-based (CCS-P) or Certified Professional Coder (CPC) Certification by AHIMA or AAPC is required.

• Develop rapport and establish and maintain effective working relationships with Cal Optima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage…