Medical Coding Auditor

Medical Coding Auditor page is loaded## Medical Coding Auditor locations:
Springfield, ORtime type:
Full time posted on:
Posted Todayjob requisition :

* Join Pacific Source and help our members access quality, affordable care!
*** Pacific Source is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age.
** Pacific Source values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The Medical Coding Auditor is responsible for researching and resolving grievances and appeals within the commercial line of business, applying advanced adjudication expertise, clinical interpretation, and decision-making. This role contributes to the development and refinement of claims research policies and procedures, with a focus on process improvement. The auditor supports complex claims and workflows requiring in-depth knowledge of clinical data, billing and coding standards, system functionality, and claims procedures.

Additional responsibilities include identifying potentially fraudulent claims, reviewing documentation for final determinations, and coordinating recovery efforts for erroneous payments resulting from processing errors, misrepresentative billing, fraud, or abuse.
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* Essential Responsibilities:

*** Participate in the provider and member appeals process; apply advanced adjudication expertise to resolve complex claim issues.
* Provide high-level guidance on claims and processes requiring in-depth research and analysis; conduct initial clinical evaluations, request and review medical records, and perform coding research using CPT, HCPC, and ICD-10 standards, including unlisted procedures and code changes.
* Review claims received through the Advanced Rebill and Compliance queues; demonstrate expertise in medical documentation, billing and coding practices, compliance requirements, and claims processing guidelines.
* Serve as a lead resource during system upgrades; function as the interdepartmental point of contact for testing and support, create and review documentation, and facilitate training on system changes.
* Perform audits to support tracking and reporting; develop and maintain audit tracking tools to share with managers and team leads and analyze audit data to identify key issues and retraining opportunities.
* Provide guidance and education to internal departments on billing and coding standards, medical record review, and claims processing guidelines, support Configuration Analysts, Provider Service Representatives, Sales Representatives, and other internal stakeholders.
* Develop and maintain collaborative relationships across departments to support shared goals and initiatives.
* Conduct detailed research on complex claims requiring additional review; perform clinical evaluations, medical record analysis, coding research, and system edit reviews.
* Establish standards to measure progress and communicate outcomes with Claims teams and other departments, support performance tracking and continuous improvement.
* Develop and manage project plans for large initiatives impacting multiple areas; ensure coordination and timely execution across teams.
* Support internal and cross-departmental quality improvement initiatives; contribute to process enhancements and compliance efforts.
* Document issues affecting claims processing quality and communicate concerns to team leaders and relevant departments; use established channels to escalate problems appropriately.
* Conduct fraud, waste, and abuse audits in alignment with compliance and audit work plans; prepare audit reports for management and legal counsel.
* Investigate and resolve billing and coding-related inquiries and complaints from members,…