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Payment Integrity Coding Coordinator

Blue Cross Blue Shield of Arizona

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Location:
United States , Phoenix

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Category:
Finance

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Contract Type:
Not provided

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Salary:

Not provided
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Job Description:

The Coding Coordinator is responsible for performing audit activities in the areas of data mining, contract compliance, itemized bill reviews and provider outreach/education for all claim types to validate correct claims coding and billing practices. This role includes the identification and correction of abusive and wasteful billing and coding practices by conducting pre and post-payment coding compliance audits, communicating recommended solutions, and facilitating corrections, recovery of overpayments and provide education to promote correct, accurate and consistent coding and billing practices among providers.

Job Responsibility:

  • Perform audit activities in the areas of data mining, contract compliance, itemized bill reviews and provider outreach/education for all claim types to validate correct claims coding and billing practices
  • Identify and correct abusive and wasteful billing and coding practices by conducting pre and post-payment coding compliance audits
  • Communicate recommended solutions, and facilitating corrections, recovery of overpayments and provide education to promote correct, accurate and consistent coding and billing practices among providers
  • Through data analysis, identify areas of high risk for coding and billing variances
  • Collaborate with analyst to define reporting criteria to evaluate shifts in utilization and provider coding patterns
  • Interprets data, draws conclusions, and reviews findings with all levels within the organization
  • Conducts audits of claims by selecting claims that have been identified as in scope for audit
  • Audits claims, medical records and corresponding documentation for appropriate coding
  • Applies knowledge of medical coding, diagnostic-related group (DRG) and current coding guidelines
  • Performs hospital charge audits and itemized bill audits on all high dollar claims and as needed on other questionable charges applicable to outpatient/professional services
  • Makes complex coding determinations and uses concise reasoning citing the principles and rational used in making the determination
  • Prepares results/recommendations of the coding audit findings to the providers via claims adjustment notification letters and / or other direct communication
  • Articulates clear and concise recommendations that may be challenged by health care providers
  • Facilitates recovery efforts of claims that were identified as incorrectly billed
  • Participate on task teams and corporate committees as required, applying coding and analytical skills
  • Quantifies the financial impact for the company and reports findings to management
  • Acts as resource person for internal and external customers regarding coding and billing practices
  • Develop, maintain and follow detailed procedures on the process and business rules around audits
  • Manages ongoing audits and meets timeliness expectations
  • Develops and maintains collaborative internal relationships
  • Attend pertinent coding seminars and training, and use other resources as applicable, to maintain current knowledge of rapidly changing coding guidelines
  • Proactively review and identify potential areas of high risk for coding and billing variances
  • Develop and maintain a thorough understanding of medical coverage and reimbursement guidelines and make independent decisions
  • Facilitates meetings to discuss areas of difficulty and variance by researching recognized national coding guidelines and medical data to encourage uniformity and consistency of coding practices among providers
  • Develop clear and concise recommendations for any potential coding or reimbursement changes including full rationalization and how it might interact with current processes and policies
  • Present recommendations to the appropriate audience for review and approval
  • Work closely with other areas of the company to ensure implementation and updates to methodologies are made timely and accurately
  • Share knowledge of skills, projects, and business needs with peers and less experienced analysts
  • Trains new employees as needed
  • Plan and lead multiple projects and cross-functional teams from inception to completion
  • Lead and/or participate on task teams and corporate committees as required, applying analytical skills and actively participating in a team environment to complete projects and accomplish goals
  • Demonstrate a strong business perspective, industry-knowledge, organizational skills and communication skills
  • Work with and present to all levels of management, including Executives
  • Independently manage and improve organizational processes
  • Evaluate and create new ways to do things while making sure to incorporate input from all key stakeholders
  • Keeps abreast of trends or technology that could improve work flow
  • Demonstrate complete ownership and accountability in all leadership roles, process improvements and recommendations
  • Identify and explore opportunities for medical and reimbursement policy changes that support claim savings goals, while maintaining focus on appropriate reimbursement levels and relativities
  • Perform independent research to identify coding and system issues that impact medical coverage guidelines and pricing, presenting recommendations for appropriate corrective measures to management following thorough analysis & independent decision, while actively participating in the resolution
  • Act as a liaison with health services, other divisions, external vendors and analysts to assure adequate communication and coordination of audit activities, medical and reimbursement policy and coding changes
  • Support and train other employees in lower levels
  • Help direct a thorough and efficient review of all audit work being produced in the area
  • Reports to a supervisor or manager who provides minimal supervision/project management
  • Develop own work-plans, and discusses timelines, prioritization, and objectives with supervisor or manager
  • Perform all other duties as assigned

Requirements:

  • 2 years of experience of professional/physician, inpatient, diagnostic and procedural coding, claims administration, claims auditing or related experience required
  • High-School Diploma or GED in general field of study
  • Certified Professional Coder (CPC), or Certified Inpatient Coder (CIC)
  • Intermediate skill in use of office equipment
  • Intermediate PC proficiency
  • Intermediate proficiency in spreadsheet and word processing software
  • Basic skill in mathematics
  • Knowledge of medical terminology, ICD-10 CM & PCS, CPT and DRG codes
  • Ability to read, analyze, and interpret technical procedures, medical reports, fee schedules and medical coverage guidelines
  • Broad understanding of health insurance terms and concepts
  • General knowledge of the healthcare industry
  • Knowledge of coding principles and code sets including UB92, CPT, HCPCS, ICD 10, ADA, and ASA
  • Knowledge of UB92 guidelines. Knowledge of Medicare rules and regulations
  • Awareness of claims processes and claims processing systems
  • Meticulous attention to detail
  • Ability to deal with ambiguity and make recommendations with less than complete or conflicting information while maintaining appropriate time management
  • Ability to maintain confidentiality and privacy
  • Ability to communicate effectively, both orally and in writing, to peers and direct management
  • Ability to build and maintain productive working relationships with others
  • Skill in prioritizing tasks and working with multiple priorities, sometimes under limited time constraints
  • Ability to summarize coding information to a general audience
  • Proactive about requesting enough information to fully understand and meet the business need
  • Analytical knowledge necessary to generate reports based on available data and then make sound decisions based on reported data

Nice to have:

  • 4 years of experience of medical coding, claims administration, claims auditing or related experience
  • 2 years of relevant hospital inpatient coding experience including DRG assignment
  • Experience with coding of all claim types
  • Associate or bachelor’s Degree in any general field of study
  • Advanced skill in use of office equipment
  • Knowledge of BCBSAZ corporate structure, functions, and procedures
  • Advanced proficiency in spreadsheet and word processing software
  • In-Depth knowledge of BCBSAZ products, processing systems, files, and computer software
  • Knowledge of fee schedules and medical coverage guidelines
  • Ability to communicate effectively, both orally and in writing, to all levels in all departments
  • Project management skill needed to create timelines, track deliverables and progress, resolve issues, and communicate project status

Additional Information:

Job Posted:
December 27, 2025

Employment Type:
Fulltime
Work Type:
Remote work
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