Clinical Coding Lead

Job Summary:

The Clinical Coding Lead works directly with the VP, Medical Services and Director of Clinical Policy in the development, maintenance and execution of integrating clinical policies with appropriate coding.

Essential Functions:

• Assist in the oversight of the clinical coding process
• Develop strategy and implementation plan to integrate appropriate coding with clinical policies and Reimbursement policies
• Maintain close collaboration with the Benefit/Coding/Support teams in code set matching to Clinical and Reimbursement policies
• Develop, implement and maintain coding policies and procedures
• Review and analyze clinical policies to identify necessary coding requirements
• Assign and implement appropriate clinical codes in accordance with industry standards and regulations
• Collaborate with clinical teams to ensure accurate coding practices are followed
• Monitor and audit coding processes to ensure compliance and accuracy
• Ensure all codes are set up correctly and payment processes are aligned with coding practices
• Provide training and support on best practices and updates to coding guidelines
• Ensure adherence to all relevant coding guidelines, requirements and regulatory standards
• Stay current with changes in coding regulations and clinical policies to maintain compliance
• Report audit outcomes and communicate to stakeholders
• Investigate and resolve coding discrepancies and address complex coding issues
• Lead initiatives to improve coding efficiency and accuracy.
• Collaborate with Utilization Management in prior authorization list confirmation and optimizing the accuracy of the Prior Authorization Look up tool
• Identify and assess risks related to coding, billing and documentation and develop strategies to mitigate those risks
• Perform any other job duties as requested

Education and Experience:

• Bachelor's Degree in a related field or equivalent years of relevant work experience is required
• Master's degree preferred
• Experience working as a Certified Coding Specialist (CCS) preferred
• Minimum of seven (7) years of experience in health care is required
• Minimum of five (5) years of experience working in medical coding, including experience in physician and outpatient coding (HOPPS) is required
• Minimum of three (3) years auditing experience preferred
• MCO/HealthPlan experience preferred
• Experience with Facets preferred

Competencies, Knowledge and Skills:

• Expert level understanding of coding guidelines

• ICD-10 Proficiency: Ability to accurately apply ICD-10 codes for diagnoses and procedures.
• HCPCS Knowledge: Familiarity with the Healthcare Common Procedure Coding System (HCPCS) for billing and coding.
• CPT Understanding: Experience with Current Procedural Terminology (CPT) codes for documenting medical services and procedures

• Working knowledge of inpatient coding

• Ability to analyze complex data and resolve coding and billing discrepancies
• Proficient in Microsoft Excel, Word, PowerPoint, Excel and on-line coding resources
• Proficiency in coding software and healthcare management systems is required
• Critical listening and systematic thinking skills
• Planning, problem identification and resolution skills
• Business process/management skills
• Ability to maintain confidentiality and act in the company's best interest
• Strong oral, written, and interpersonal communication skills
• Excellent leadership, management and supervisory skills and experience
• Energetic, enthusiastic, and politically astute
• Ability to act with diplomacy and sensitivity to cultural diversity
• Responsive to a changing environment
• Strategic deployment and management skills
• Conflict resolution skills
• Knowledge of regulatory reporting and compliance requirements
• Proficiency with quality improvement, performance improvement and operations
• Ability to work with multi-disciplinary departments across the organization
• Demonstrated ability to develop, prioritize and accomplish goals
• Strong interpersonal skills and high level of professionalism
• Ability to work independently and within a team environment

Licensure and Certification:

• Current, unrestricted license as a Registered Nurse (RN) is preferred
• Coding certification (CPC, CPC-P, or CCS,) required

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:
$81,400.00 - $130,200.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:
Salary

Competencies:
- Create an Inclusive Environment
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.

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