Medical Coder, Program Integrity

Your Future Evolves Here

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.

Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.

Join Evolent for the mission. Stay for the culture.

What You’ll Be Doing:

The Program Integrity Coder- FWA Auditor is responsible for verifying the accuracy of itemized, complex claim review for payment, coding, and billing guidelines in accordance with the Plans’ provider agreements and the National Healthcare Billing Audit guidelines. The successful candidate must be capable of building and maintaining strong working relationships with key internal and external constituents and working effectively in a matrixed environment.

Responsibilities:

• Work with SIU Investigators assisting in research, discuss to make appropriate coding determinations as needed

• Analyze and interpret patient medical records (behavioral related and other specialties) pertaining to FWA investigations as needed

• Compare information submitted on the claims to determine amount and nature of billable services as needed

• Determines appropriateness of billing and reimbursement as needed

• Documents findings for each claim line in a spreadsheet as needed

• Summarize findings in a written report as needed

• Abstracts CPT, HCPCS, Revenue Codes, DRG codes, and ICD-10 from medical records as needed

• Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations as needed

• Perform data analysis and lead generation/data mining of client data as needed

• Provide Subject Matter Expertise and SIU support to clients as needed

• Comply with Privacy and Security standards

• Understands and complies with all company Privacy and Security standards

• Other duties as needed

Qualifications (Required & Preferred):

• Knowledge of anatomy, medical terminology, and billing

• In-depth knowledge of and ability to interpret ICD-10-CM/PCS, HCPCS/CPT,

• Knowledge of APR-DRG, MS-DRG codes and DRG grouping systems and Plan benefit designs

• 1-2 years’ experience reviewing and auditing medical records, working in a health plan or health insurance, or similar environment

• Ability to identify and abstract information from medical records (paper or electronic) to ensure coding guidelines are met

• Knowledge of specialty medical practices

• Must be detail oriented

• Ability to communicate effectively both verbally and in writing

• Strong listening skills

• Independent

• Responsible

• Self-disciplined

• Ability to meet defined performance and production goals

• Strong computer skills: – proficient in MS Word, Excel, PowerPoint and Outlook, familiarity with Electronic Medical Record systems and Encoders

• Consistently meets coding quality standards and thresholds

• Bachelor’s degree

• Knowledge of Health Insurance, Managed Care, Benefit Design, Medicaid, Medicare Advantage and Federal Regulations

• Hands-on work with complex medical and billing information preferred

CERTIFICATE/LICENSE (REQUIRED)

• Active Certified coder (RHIA, RHIT, CPC, CPMA, CIC, COC or CCS-P) REQUIRED; candidate would need to maintain active certif