Partner with Clinical, Claims, and Payment Integrity peers to review claims for DRG related issues on a prospective and retrospective basis that drive inaccurate payments to providers.
Proactively identify overpayments to ensure accurate claims payments on inpatient services.
Participate in collaborative discussions with MDs to verify the clinical rationale behind billed procedures.
Perform inpatient coding audits and review services remotely.
Identify trends and suggest corrective action plans.
Provide in-service education to clients on coding trends.
UASI has over 40 years of experience and enduring partnerships with its valued clients. The company was recognized as a Top Workplace by the Cincinnati Enquirer in 2022, 2023 and 2024, with a dedicated team and long-term success.
Research and document new payment integrity concepts by analyzing medical policies, billing regulations, and reimbursement logic.
Translate complex billing rules into precise technical specifications for automated claim auditing algorithms.
Conduct hands-on data analysis using Microsoft Excel to explore datasets and quantify savings potential for clients.
Cohere Health's clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. They work with over 660,000 providers and handle over 12 million prior authorization requests annually. The Coherenauts who succeed here are empathetic teammates who are candid, kind, caring, and embody their core values and principles.
Accurately translate patients’ medical records into standardized codes for diagnoses and treatments.
Ensure compliance with legal, regulatory, and organizational standards.
Ensure claims are processed correctly and on time through clear communication and efficient management of records.
Dignity Health Medical Foundation provides comprehensive health care services. They have care centers throughout California and are affiliated with Dignity Health, one of the largest health systems in the nation. They strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships.
Perform daily audits on provider appeals for completeness and accuracy based on specified coding guidelines.
Stay current on coding guidelines appropriate to the position; learn new appeal categories as production needs require.
Professionally communicate finds, errors, and suggestions to facilitate on-going communications and efficient department operations.
Cotiviti focuses on claims audits for appeals, checking for completeness & accuracy based on coding guidelines. They offer a team-oriented environment and a comprehensive benefits package to address various personal and family needs.
Submit clean, timely claims with accurate CPT, HCPCS, ICD-10 codes, and modifiers.
Review provider documentation and assign accurate codes per ICD-10-CM, CPT, and HEDIS/quality reporting guidelines.
Maintain and contribute to the internal billing rules matrix (payer, state, provider type, modifiers).
Imagine Pediatrics is a tech-enabled, pediatrician-led medical group that reimagines care for children with special health care needs. They deliver 24/7 virtual-first and in-home medical, behavioral, and social care. They enhance existing care teams with compassion, creativity, and an unwavering commitment to children with medical complexity.
Accurately code diagnoses, procedures, and other services to ensure medical records and billing are accurate.
Work with providers to ensure documentation is clear and complete, resulting in accurate coding.
Review all claim edits and correct errors in a timely fashion, coding for practice and hospital charges for all departments supported by the Professional Billing Office.
ProMedica is a mission-driven, not-for-profit health care organization that provides acute and ambulatory care, a dental plan, and academic business lines across nine states. The organization operates 10 hospitals and employs over 1,300 healthcare providers through ProMedica Physicians, with a culture committed to improving health and well-being, earning national recognition for clinical excellence.
Review clinical documentation and diagnostic results to extract data and apply appropriate ICD-10-CM and ICD-10-PCS codes for various purposes.
Abide by the Standards of Ethical Coding and official coding guidelines, staying updated on coding changes and interpretations.
Perform detailed reviews of Inpatient records, assign diagnosis and procedure codes, and meet established productivity guidelines with high accuracy.
Rochester Regional Health is an integrated health services organization serving the people of Western New York, the Finger Lakes, St. Lawrence County, and beyond. The system includes nine hospitals; primary and specialty practices, rehabilitation centers, ambulatory campuses and immediate care facilities; innovative senior services, facilities and independent housing; a wide range of behavioral health services; and Rochester Regional Health Laboratories and ACM Global Laboratories, a global leader in patient and clinical trials.
Accurately codes and abstracts outpatient medical records utilizing ICD-10-CM and CPT-4 coding systems.
Assigns modifiers when appropriate.
Must be able to maintain a minimum 95% coding accuracy.
Montefiore St. Luke’s Cornwall (MSLC) has been a cornerstone of high-quality healthcare in Orange County for 150 years. MSLC is a member of the Montefiore Health System and provides care to more than 250,000 patients annually; it strives to be the employer of choice by offering comprehensive benefit packages.
Own the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations.
Design and oversee a robust audit program that monitors adjudication system output against clinical policies, pricing, benefit rules, and provider contract terms.
Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies and contract validation.
Clover Health aims to improve the health of its members by leveraging technology and data-driven insights to provide personalized, high-quality care. They are a mission-driven team of individuals, who are passionate about solving healthcare's most complicated problems, and strive to put members first.
Support medical policy functions by providing medical coding and system configuration support.
Perform coding analyses and utilization reporting to recommend medical policy updates.
Participate in cross-functional meetings to align with enterprise strategic priorities.
Wellmark is a mutual insurance company owned by policy holders across Iowa and South Dakota, built on over 80 years of trust. Motivated by the well-being of members, they are committed to service, sustainability and innovation.
Evaluate and present audit results and educational instruction to physicians, coders, and staff.
Review clinical documentation to ensure adherence to billing guidelines and internal coding policies.
Provide instruction on documentation standards and correct use of CPT‑4 and ICD‑10 codes.
Pediatrix Medical Group is a leading provider of specialized healthcare for women, babies, and children. Since 1979, they've grown into a national, multispecialty medical group with a commitment to coordinated and compassionate care, bolstered by investments in research, education, and safety.