Clinical Coder
2 months ago
**Profile**:
- We offer remote work opportunities (AK, AR, AZ, CA, *CO, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only).Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.Veterans, Reservists, Guardsmen and military family members are encouraged to apply**Job Summary**
Conducts retrospective medical claim reviews and claims adjudication for coding determinations. Provides coding-related information to medical directors, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management and the claims subcontractor as needed. Functions as the designated recipient for factual network provider claim review requests. Develops determination letters. Provides support to non-clinical and clinical staff on coding and retrospective medical claims review processes.
**Education & Experience**
**Required**:
- Current Certification as a Professional Coder (CPC) or Certified Professional Coder Hospital (through the American Academy of Professional Coders)
- If supporting TRICARE contract, must be a U.S. Citizen
- If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- 2+ years of clinical coding experience
- 2+ years of claims processing experience
**Preferred**:
- Experience in the private medical industry, health insurance or Managed Care field
- Experience in a fast-paced corporate environment
- Familiarity with TRICARE and the military healthcare delivery system
**Key Responsibilities**
- Performs claims coding reviews using current coding guidelines.
- Performs focused claims reviews as requested by management and summarizes findings.
- Identifies and reports potential fraudulent or quality issues.
- Acts as a resource for TriWest staff on ICD-10-CM, HCPCS and CPT coding.
- Researches TRICARE manuals for benefits, limitations and exclusions and current coding guidelines.
- Monitors and tracks timeliness of retrospective claims reviews response to ensure compliance with required timelines for completion of assigned reviews.
- Identifies questionable review decisions and forwards to the appropriate Medical Director for evaluation and/or corrective action.
- Provides accurate data entry in the medical management and claims system.
- Performs other duties as assigned.
- Regular and reliable attendance is required.
**Competencies**
**Communication / People Skills**:Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
**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.
**Independent Thinking / Self-Initiative**:Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.
**Information Management**:Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.
**Organizational Skills**:Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
**Problem Solving / Analysis**:Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.
**Team-Building / Team Player**:Influence the actions and opinions of others in a positive direction and build group commitment.
**Technical Skills**:Knowledge of ICD-10, HCPCS and CPT coding; ability to maintain the confidentiality and security requirements of medical records; ability to meet department performance standards.
**Working Conditions**
**Working Conditions**:
- Availability to work any shift
- Works within a standard office environment, with mínimal travel
- Extensive computer work with prolonged sitting
**Company Overview**:
**Taking Care of Our Nation’s Heroes.**
**It’s Who We Are. It’s What We Do.**
Do you have a passion for serving those who served?
**Join the TriWest Healthcare Alliance Team We’re On a Mission to Serve®**
Our job is to make sure that America’s heroes get connected to health care in the community.
At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.
**DoD Statement**:
Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.
**Benefits**:
We’re more than just a health care company. We’re passionate about serving others We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and y
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