Medical Coding Professional - E&M Specialty Thryve Digital

7.0 - 9.0 years

27 Lacs

hyderabad, chennai

Work from Office

Role Summary: Review patient medical records based on review request from FIPR claims review team to identify incorrectly coded services (CPTs)/diagnoses (ICDs), Modifiers, DRGs, APCs which are not coded according to the coding guidelines laid down by the apex organizations like AMA, CMS (Medicare/Medicaid), or other recognized bodies/associations and the policies/guidelines laid down by payors for specific services. This department is responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports. The incumbent is responsible for conducting coding audits to identify alleged fraud, waste and abuse perpetrated by providers, members, facilities, pharmacies, groups and/or employees of the organizations and Subsidiaries based on their qualified areas. The incumbent is responsible for interviews which might include providers and members and may be conducted onsite or offsite. The incumbent is also responsible for the field investigative work necessary to complete a review of a special project, potential fraud, waste, and abuse case, conducting the initial investigations and coordinating the recovery/savings of money related to fraud, waste, and abuse. The incumbent must be able to testify in a court of law, prepare cases for referral to various federal, state, and local law enforcement entities and work with those agencies through closure of the case. Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements. Essential Responsibilities Review medical records as pre requests from the claims review team as assigned by the supervisor to check the correctness of the coding and submit findings with detailed notes that can support. Responsible for completing all necessary field (externally) coding investigative work for resolution or alleged fraud/waste and abuse cases or special projects. Provides advisory support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee. Required Must Have: Medical doctors (MBBS, BHMS, BAMS, BUMS), BSc. Nursing. BPT, BOT, Microbiology, or equivalent from a reputed university holding a license with clinical exposure (Dentists are not being considered) with in depth knowledge of Anatomy, Physiology, and disease processes Must be a Certified Medical Coder with a valid certification from AAPC (CPC, COC, CIC, CIRCC, CPMA, or other specialty certifications AND/OR AHIMA (CCS, CCS-P) Must have a minimum of 2 years of experience in at least one major specialty as listed above under skills with hands-on experience in reviewing and coding medical records based on coding guidelines. Must be adept in Coding basics, Coding guidelines from AMA, CMS, or other relevant bodies and familiar with policy guidelines from various payors and should be familiar with coding references and how to use them. Good to Have: Knowledge on payor side business and denial handing experience would be an added advantage. Relevant, progressive experience in the health insurance industry and/or healthcare fraud investigations Exposure to professional billing/facility billing, Patient Financial Services, HIM, Internal Audit, Professional/Facility Reimbursement or Provider contracting, etc. Educational Background: MBBS, BAMS, BUMS, BHMS, B.Sc. Nursing, B.Sc. Microbiology, B.Sc. Radiology, B.Sc. Biotech, Bachelors (Occupational Therapy), Bachelors (Speech Therapy) Additional Details: Medical Coder with a valid certification from AAPC(CPC,COC,CIC,CIRCC,CPMA, are other specialty certifications AND/OR,AHIMA(CCS,CCS-P)

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