Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
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Sr. Inpatient/DRG Coding Integrity Auditor (Remote)
- 📁
- Manager & Professional
- 💼
- EmblemHealth
- 📅
- Mar 21, 2026 Post Date
Summary of Position
Responsible for upholding the standard for code review functions in the setting of business/industry/legislative issues relating to, and impacting, quality coding audit and compliance issues. Identify inconsistencies and coding compliance risks between EH reimbursement policies and claims which directly impact claim payment (i.e. authorizations) and responsible for working with leadership to bring to resolution. Audit inpatient and outpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed.
Principal Accountabilities
- Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment.
- Review reporting for outlier provider claims; request patient medical records to assign diagnoses, treatments, and surgical and non-surgical procedures for facility and medical services for coding and payment integrity.
- Analyze and audit claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
- Identify potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
- Provide audit reporting, results, and recommendations to management and SIU as appropriate.
- Analyze results to assess compliance with regulations, identify procedural weaknesses and education needs that contribute to instances for non-compliance both to business, external business partners, and providers.
- Prepare formal written reports summarizing current state (findings), desired future state, and critical success factors.
- Perform audits of changes to coding introduced by new medical policies, reimbursement policies, regulatory changes, and business requirements on a quarterly basis.
- Participate in RPC, RPCW, Medical Policy Committee (MPC) and Medical Policy Committee Workgroup (MPCW) as added Coding Integrity representation at meetings; ensure that decisions are appropriate and will result in accurate.
- Claim reimbursement.
- Identify reimbursement and coding variances from industry standards and brings to leader’s attention.
- Continuously gains knowledge of CPT, ICD, HCPCS and business/industry/legislative issues relating to and impacting Quality Coding Audit and Compliance issues.
- Perform related tasks as directed or required.
Qualifications
- Bachelor’s degree, preferably in a healthcare, quantitative/analytical, or business-related field of study
- AAPC CPC (AAPC Certified Professional Coder) & AAPC CIC (Certified Inpatient Coder)/or CCS (AHIMA Certified Coding Specialist)
- AAPC CPMA (AAPC Certified Professional Medical Auditor)
- 4 – 6+ years of coding experience
- 1+ year auditing experience
- Extensive knowledge of inpatient DRG clinical documentation review
- Additional related work experience/specialized training may be considered in lieu of educational requirements
- Proficiency with MS Office (Word, Excel, Access, PowerPoint, Outlook, Teams, etc.)
- Attention to detail; and ability to communicate or escalate issues in a timely manner
- Ability to independently prioritize and complete multiple tasks with competing priority levels and deadlines
- Ability to perform effectively in a fast-paced work environment
- Excellent communication skills (verbal, written, presentation, interpersonal) with all types and levels of audiences
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, Emblemhealth may provide work visa sponsorship for certain positions.