Nurse Coding Advisor

Healthfirst Remote, New York
nurse advisor medical data billing management nurse fraud providers waste medical billing compliance regulatory
November 23, 2022
Healthfirst
Remote, New York
The Nurse Coding Advisor, SIU will review medical records for possible fraud, waste, and/or abuse (FWA) and draft high-level summaries of his/her findings. The Coding Advisor will also educate providers regarding proper coding and documentation processes, and partner with senior and executive level leaders across Healthfirst to provide coding expertise. This is a critical role that directly supports Healthfirst’s strategy with regard to mitigating risk and exposure associated with fraud, waste and abuse.

Duties/Responsibilities:

  • Act in an advisory capacity to departments and senior-level leadership on medical billing and coding practices through analysis of medical billing and coding data and supplemental data sources
  • Analyze information contained in medical claims processing data (e.g. ICD-10, CPT, HCPCS, revenue codes) to determine provider billing patterns; identify trends and compare observations to standard or expected billing patterns
  • Provides formalized Provider Education, written and oral, with feedback and suggestions to providers regarding coding accuracy. Partnering with Providers for improvements and increased communication and support.
  • Evaluate business processes to identify enhancement or improvement opportunities to impact FWA lead selection; collaborate with SIU/PI & HF to develop and implement new or enhanced practices
  • Proactively identify instances of potential FWA and continuously improve identification techniques through data analysis using a variety of analytics, system tools, and industry research
  • Use knowledge of healthcare coding conventions, medical billing procedures, fraud schemes, general areas of vulnerability, reimbursement methodologies and relevant laws to find suspicious patterns in claims data and other sources
  • Conduct retrospective review of records and claims data for post-pay audit
  • Ensure code best suits the patient’s clinical condition according to coding regulations and patient’s recent medical care, site of that care and procedures and medical necessity
  • Ensure coding is done at the highest appropriate level of specificity supported by the medical documentation and monitor for opportunities to educate providers on documentation required for optimal specificity
  • Ensure compliance with and adhere strictly to all regulatory coding guidelines including:
    • ICD.9 and ICD.10 Official Guidelines for Coding and Reporting
    • AHA Coding Clinic for ICD.9 and ICD.10 CM
    • CMS Medicare Part C instructions and requirements for diagnostic coding
  • Additional duties as assigned

Minimum Qualifications:

  • Registered Nurse (RN)
  • Coding certification from either American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA).
  • 5 or more years’ experience as a coder
  • 3-5 years’ experience working as a nurse in a healthcare setting (doctor’s office, nursing facility, hospital, etc.)
  • Experience with Microsoft Office suite and Care Management databases

Preferred Qualifications:

  • Experience with Fraud, Waste, and Abuse (FWA)
  • Experience writing up findings on an FWA action

Compliance & Regulatory Responsibilities:

  • Ensures compliance with and adheres strictly to all regulatory coding guidelines including:
    • ICD.9 and ICD.10 Official Guidelines for Coding and Reporting
    • AHA Coding Clinic for ICD.9 and ICD.10 CM
    • CMS Medicare Part C instructions and requirements for diagnostic coding.

License/Certification:

  • Registered Nurse (RN)
  • Coding certification from either American Academy of Professional Coders (AAPC) or Certified Professional Coders (CPC) or American Health Information Management Association (AHIMA).

Please note: Since we care so greatly about our employees' and members' wellbeing, Healthfirst is moving to an environment where our employees are fully vaccinated against COVID-19. As a prospective new team member, you must be fully vaccinated with a CDC/FDA approved COVID-19 shot(s) to work in our offices. If you are selected to interview for this role, we will explain our vaccination policy in further detail and ensure you are comfortable moving forward with this company policy.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst.  Healthfirst will never ask you for money during the recruitment or onboarding process.



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