Description BKG Enterprises is seeking Medical Management Specialist to join our team! This is a work-from home opportunity! - Call Center - Monday - Friday 8am-5pm -Training pay: $18.50/hr after training pay $19.25/hr -Medical, dental, and vision insurance offered -Supplemental insurace -80 hours of PTO after 90 days -10 paid holidays Responsible for providing non-clinical support to medical management operations calls, which includes handling the most complex file reviews and inquiries from members and providers. Primary duties may include but are not limited to: - Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review). - Conducts initial review of files to determine appropriate action required. - Maintains and updates tracking databases. - Prepares reports and documents all actions. - Responds to requests, calls or correspondence within scope. - Provides general program information to members and providers as requested. - May review and assist with cases. - May collaborate with external community-based organizations to facilitate and coordinate care under the direction of an RN Case Manager. - Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information. - Acts as liaison between medical management operations and other internal departments to support ease of administration of medical benefits. Provides mentoring and work direction to lower-level associates. - Requirements - Requires a high school diploma and a minimum of 5 years administrative and customer service experience; or any combination of education and experience which would provide an equivalent background. Knowledge of managed care or Medicaid/Medicare concepts strongly preferred. - Position requires strong customer service/call center skills

Work Schedule: This is a full time, 1.0 FTE position. Shifts will be scheduled Monday – Friday. Hours may vary based on the operational needs of the department. This is a remote position. To be eligible to work remotely, you must be in an approved remote work state for UW Health. We’ve included a link below to view the full list of approved remote work states. Approved Remote Work States Listing Be part of something remarkable Advance your coding career at UW Health! We are seeking a Medical Coding Lead to: - Monitor coding operations with respect to workflows and regular reporting: evaluate workflows for maximum efficiencies and problem solve work queue issues when accounts/charges are not flowing properly, making recommendations as necessary. - Answer charging, coding, Epic or other software related questions from coders, CDI, clinical and Revenue Cycle staff. - Perform research, run various reporting and assist with general coding as needed and as requested. - Provide coding training within the Coding Department and perform research on coding issues. At UW Health, you will have: - An excellent benefits package, including health and dental insurance, paid time off, retirement plans, two-week paid parental leave and adoption assistance. - Options for a variety of schedules and shifts that offer flexibility and allow for work-life balance. - Access to great resources through the UW Health Employee Wellbeing Department that supports your emotional, financial, and physical well-being. - Tuition benefits eligibility - UW Health invests in your professional growth by helping pay for coursework associated with career advancement. - The opportunity to earn a referral bonus for referring friends, former colleagues or others to apply for open, posted positions. Qualifications - High School Diploma Required or - equivalent and Medical Coding Education Required Work Experience - 3 years progressive coding experience Required - More than five (5) years of coding experience in an academic medical center Preferred Licenses & Certifications - Certified Professional Coder (CPC) Upon Hire Required or - Certified Outpatient Coder (COC) Upon Hire Required or - Certified Inpatient Coder (CIC) Upon Hire Required or - Certified Coding Specialist (CCS) Upon Hire Required or - Certified Coding Specialist Physician-Based (CCS-P) Upon Hire Required or - Certified Coding Associate (CCA) Upon Hire Required - Registered Health Information Technician (RHIT) Preferred - Registered Health Information Administrator (RHIA) Preferred Our Commitment to Social Impact and Belonging UW Health is committed to fostering a workplace that creates belonging for everyone and is an Equal Employment Opportunity (EEO) employer. Our respect for people shines through patient care interactions and our daily work practices as we work to embrace the knowledge, unique perspectives and qualities each employee and faculty member brings to work each day. It is the policy of UW Health to provide equal opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information. Job Description UW Medical Foundation benefits

Role Description Under the guidance of the SIU Management, this position is responsible for the accurate and thorough clinical investigation of potential fraud, waste and abuse (FWA) for all lines of business. The scope of accountability includes investigating and remediating allegations of FWA while adhering to compliance and regulatory requirements. - Functions as a clinical reviewer of medical records, researching and investigating complex medical cases. - Interprets a variety of documents including provider contracts, group benefit structures, Corporate Medical Policies, AMA CPT Coding Guidelines, HCPCS coding, inter-plan regulations, and government policies. - Thoroughly researches allegations or issues and develops sources of information to create a plan of action. - Accumulates sufficient detailed evidence including statements, documents, records, and exhibits. - Evaluates situations accurately and interacts with management, medical directors, and legal, where appropriate. - Prepares comprehensive summary reports and assures accuracy of information provided to providers, regulators, law enforcement, Legal, Compliance, and outside counsel. - Prepares cases for prosecution, civil settlement, or overpayment recoupment by documenting findings clearly. - Analyzes proactive detection reports and claims data to identify red flags/aberrant billing patterns. - Manages cases as assigned, prioritizing case load as appropriate. - Maintains case logs, prepares records, and regular status reports. - Interacts with health care providers under adverse conditions due to potential FWA discovery. - Discusses sensitive material in a professional, fair, and accurate manner. - Recommends providers for referrals to the New York State Office of Professional Medical Conduct/NYS Education Department. - Acts as primary point of contact with law enforcement for assigned cases. - Prepares recommendations on preventive/corrective measures for future fraud deterrence. - Supports other SIU investigators and analysts with their cases. - Consults with external practitioners, medical professional groups, and agencies. - Maintains accurate and up-to-date knowledge of all Government Programs regulations. - Demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values. - Maintains high regard for member privacy in accordance with corporate policies. - Regular and reliable attendance is expected and required. - Performs other functions as assigned by management. Qualifications - Must meet the NYS DFS’s and the NYS OMIG’s minimum investigator requirements. - A minimum of five years in the healthcare field working in FWA investigations and audits; or five years of insurance claims investigation experience; or seven years of professional investigation experience involving economic or insurance-related matters. - Current NYS R.N. license with a minimum of three years clinical experience; medical/surgical background preferred. - Current CPC designation or must obtain CPC designation within one year of hire date. - Knowledge of medical record coding conventions (e.g. CPT, DRG, HCPCS, ICD10, etc.). - Demonstrates excellent oral communication skills and proficient writing skills. - Demonstrates proficient computer skills in Word, Excel, Internet, and email. - Ability to multi-task and balance priorities. - Excellent interpersonal skills. Requirements - Two or more years of experience in the Medical Investigator role (Level II). - Five or more years in a Medical Investigator role (Level III). - Expertise in the technology of the job. - Excellent understanding of contract benefits and corporate policies. - Excellent dispute resolution and negotiation skills. - Demonstrated superior oral communication skills and strong presentation skills. - Proficient with health systems operations and understanding of reimbursement methodologies. - Extensive experience with claims processing systems and claims flow. Benefits - Participation in group health and/or dental insurance. - Retirement plan. - Wellness program. - Paid time away from work. - Paid holidays. Compensation Range(s) - Level I (E2): Minimum: $62,400 - Maximum: $96,081 - Level II (E4): Minimum: $65,346 - Maximum: $106,929

• Review Medical Records to identify diagnoses/procedures. • Perform accurate and timely coding of medical records using ICD-10-CM, CPT, and HCPCS codes. • Ensure compliance with federal and state regulations, payer guidelines, including Medicare and Medicaid guidelines and company policies. • Act as a liaison between the coding team and other departments, such as billing, compliance. • Work closely with OBGYN physicians, advanced practice providers, nurses, and administrative staff to ensure accurate coding and billing. • Track and request outstanding claims for assigned departments / facilities. • Implement best practices and innovative solutions to enhance coding operations.