Program Integrity Coding & Research Analyst – Health Plan Experienced

CareSource

. Act as a Medical Coding subject matter expert for complex coding concerns and serve as primary coding resource for Program Integrity .

Posted 10/13/2026full-timeRemote • United StatesSeniorLead💰 $72,200 - $115,500 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Medical Coding, particularly in Program Integrity and audit processes, with a strong focus on analyzing claims submissions and reimbursement methodologies. Proven ability to lead cross-functional teams and implement process improvements while maintaining effective stakeholder relationships.

Highest-signal resume keywords

Medical Coding ExpertiseProgram Integrity Coding Audit ExperienceReimbursement Methodology (APC, DRG, OPPS)Certified Professional Coder (CPC)AI Tools and Processes Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

CPT CodingICD10 CodingHCPCS CodingDRG CodingClaims AnalysisQuality Audit ProgramsRisk-Based Audit PlanningClaims Reimbursement MethodologiesProcess Improvement AnalysisSystem Configuration Analysis

Soft Skills

Effective CommunicationProblem-SolvingInterpersonal SkillsTime ManagementCritical Thinking

Tools & Technologies

Microsoft Office ToolsetAI Auditing WorkflowsTicketing System

Certifications & Qualifications

Certified Professional Coder (CPC)

Industry Keywords

Medicaid PolicyProvider ClaimsAudit LifecycleStakeholder EngagementQuality Assurance

About the role

Key responsibilities & impact

Act as a Medical Coding subject matter expert for complex coding concerns and serve as primary coding resource for Program Integrity
Analyze complex provider claims submissions using CPT, ICD10, HCPCS, DRG, and REV coding rules
Determine root causes of provider claim issues and resolve them by analyzing system configuration, payment policy, and claims data
Oversee quality audit programs for internal coding validation analysts and produce monthly reports for managers
Research policy impacts and communicate those impacts based on audit type and business risk
Assist in developing and implementing an annual risk-based audit plan for high-risk providers
Act as subject matter expert for claim accuracy audits throughout the audit lifecycle, including disputes
Lead automation requirements for AI auditing workflows, including quality assurance of policy summaries, checklists, and reference materials
Collaborate in maintaining effective internal training processes
Serve as primary contact for state and market provider escalations
Participate in legal activities, including discovery, trial preparation, and testifying as needed
Build working relationships with Markets and departments to resolve systemic issues and drive process improvements
Research and analyze functional performance and recommend enhancements, cost savings initiatives, and process improvements
Identify and resolve inconsistencies and gaps in audit capabilities and processes
Identify, document, and report issues with claims reimbursement methodologies
Support entry and tracking of system change requests through the appropriate ticketing system
Act as primary resource and subject matter expert in corporate meetings and projects
Analyze and report measurable efficiency or financial savings related to process improvements
Perform other job-related duties as requested

Requirements

What you’ll need

Bachelor's degree in Business Administration or related field required, or equivalent years of relevant work experience in lieu of required education
Seven (7) years of experience in medical coding, including program integrity coding audit experience required
Five (5) years of experience working with Medicaid policy in developing, analyzing and consulting preferred
Experience using AI tools and processes preferred
Experience with reimbursement methodology (APC, DRG, OPPS) required
Proficient in Microsoft Office toolset
Proven ability to establish effective working relationships with stakeholders at all different levels
Excellent written and verbal communication skills
Effective identification of business problems, assessment of proposed solutions, and understanding of stakeholder needs
Ability to work independently and within a team environment
Ability to multi-task and prioritize work to meet project deadlines
Effective listening and critical thinking skills
Flexibility during organizational and/or business changes
Strong interpersonal and relationship building skills
Effective problem-solving skills with attention to detail
Ability to effectively and efficiently lead and/or work within a project team
Time management skills
Customer service oriented
Decision making/problem solving skills
Ability to develop, prioritize and accomplish goals
Ability to coordinate and lead cross-functional teams
Certified Professional Coder (CPC) or equivalent billing/coding designation required
General office environment; may be required to sit or stand for extended periods of time
Travel is not typically required

Benefits

Comp & perks

Bonus tied to company and individual performance may be available
Substantial and comprehensive total rewards package
Equal Opportunity Employer environment fostering belonging and support for individuals of all backgrounds