Veterans, Reservists, Guardsmen and military family members are encouraged to apply!! 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, TX, UT, VA/DC, *WA, WI and WY only)

Job Summary

Reviews medical documentation to determine correct coding on submitted medical and behavioral health claims utilizing appropriate clinical staff resources as needed to assist in review. Update authorizations as necessary with appropriate codes.

Education and Experience

Required:

High school diploma or G.E.D. 1+ years claims review experience U.S. Citizenship - if assigned to TRICARE contract Must be able to receive a favorable interim and adjudicated final Department of Defense (DoD) background investigation - if assigned to TRICARE contract Medical terminology knowledge 1+ years working with medical documentation Preferred:

Claim coding experience

Knowledge of Behavioral health claims review

Certified Processional Coder (CPC)

Key Responsibilities

Conducts medical documentation review to determine appropriateness of coding of service. Validates medical determinations through research of resources including regulatory manuals, computer files and documentation. Assists in preparation of cases for program payment or medical director review as indicated. Validates all appropriate data is supplied with program invoice. Reviews Authorization data for process improvements. Ensures contract compliance for timelines regarding resolution of medical documentation review and updates. Communicates effectively with management and peers. Consistently meets quotas for position. Identifies and reports any potential quality or fraud issues to management, Quality Management or Program Integrity as needed. Provides support regarding clinical and coding questions. Performs other duties as assigned. Regular and reliable attendance is required.

Competencies

Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback. Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation. 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. High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow. Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented. Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Technical Skills: Thorough knowledge of policies and procedures, Managed Care concepts and medical terminology. Proficient with claim and coding tools such as Find-a-Code, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Ability to meet or exceed production standards in compliance with contract

Working Conditions

Working Conditions:

Must be available to cover any work shift Works within an office environment with minimal travel required. Extensive computer work with prolonged sitting.