Sr Clinical Coder

Job Title: Sr. Clinical Coder

Location: 100% Remote

Duration: 6 months (Contract to Hire)

Shift: 5x8 Hour Shifts MondayFriday

Job Summary:

• Conducts retrospective medical claim reviews and adjudication for coding determinations. Provides codingrelated information to medical directors providers peer reviewers Claims Administration Program Integrity Quality Management and the claims subcontractor as needed. Serves as the designated recipient for factual network provider claim review requests develops determination letters and supports both nonclinical and clinical staff on coding and retrospective medical claims review processes.

Key Responsibilities:

• Perform claims coding reviews using current coding guidelines.
• Conduct focused claims reviews as requested by management and summarize findings.
• Identify and report potential fraudulent or quality issues.
• Serve as a resource for TriWest staff on ICD10CM HCPCS and CPT coding.
• Research TRICARE manuals for benefits limitations exclusions and current coding guidelines.
• Monitor and track timeliness of retrospective claims reviews to ensure compliance with required timelines.
• Identify questionable review decisions and escalate to the appropriate Medical Director for evaluation and/or corrective action.
• Provide accurate data entry in medical management and claims systems.
• Perform other duties as assigned.
• Regular and reliable attendance is required.

Working Conditions:

• Availability to work any shift.
• Works within a standard office environment with minimal travel.
• Extensive computer work with prolonged sitting.

Education & Experience

Required:

• Current Certification as a Professional Coder (CPC) or Certified Professional Coder Hospital (through the American Academy of Professional Coders).
• If supporting TRICARE contract must be a U.S. Citizen.
• If supporting TRICARE contract must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation.
• 2 years of clinical coding experience.
• 2 years of claims processing experience.
• Preferred:
• Experience in the private medical industry health insurance or Managed Care field.
• Experience in a fastpaced corporate environment.
• Familiarity with TRICARE and the military healthcare delivery system.
• Technical Skills:
• Knowledge of ICD10 HCPCS and CPT coding.
• Ability to maintain the confidentiality and security requirements of medical records.
• Ability to meet department performance standards.