Triwest Remote Jobs in Arizona (NOW HIRING)

Summary:

Under the direction of the DRG Supervisor or designee, the Medical Claims Coding Specialist conducts retrospective medical claims review for coding and pricing determinations, focusing on both outpatient and inpatient services. As a subject matter expert, this role provides coding-related information to various departments and functions as the designated recipient for factual network provider claim review requests.

Responsibilities:

• Serve as the subject matter expert on ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding of medical claims.
• Lead coding projects as directed by Clinical Operations management.
• Provide training and mentoring for new and existing Clinical Coders.
• Perform DRG Validation of medical claims coding using current coding guidelines and support software.
• Conduct focused outpatient and/or inpatient claims reviews and summarize findings.
• Identify and report potential fraudulent or quality issues.
• Act as a resource for TriWest staff on coding queries.
• Research TRICARE manuals to assist with the Referral and Authorization Decision Support tool process.
• Monitor timeliness of retrospective claims reviews to ensure compliance with required timelines.
• Prepare determination notices and other written correspondence.
• Identify questionable review decisions and escalate to the appropriate Medical Director.
• Provide accurate data entry in the medical management and claims system.
• Review and document coding issues identified by the TRICARE Quality Monitoring Contractor.
• Perform other duties as assigned, ensuring regular and reliable attendance.

Qualifications:

• High School Diploma or GED.
• Current certification as Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), or Registered Health Information Technician (RHIT).
• U.S. Citizenship required.
• Ability to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation.
• Minimum 5 years of clinical coding experience for facility and/or professional accounts.
• Minimum 3 years of claims processing experience for inpatient and/or outpatient accounts.
• Documented experience in a fast-paced environment.
• Preferred experience in the private medical industry, health insurance, or Managed Care field.
• Familiarity with TRICARE and the military healthcare delivery system is preferred.
• Advanced knowledge of ICD-10-CM, ICD-10 PCS, HCPCS, and CPT coding; proficiency with Word and Excel.
• Strong problem-solving, organizational, and communication skills.
• Ability to function in a multi-system Microsoft environment.

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