Permanent opportunity with a health insurance company who is looking for a Coder.
To function as a senior clinical and technical expert that manages interpretation of industry standards for procedural and diagnostic coding and all payment methods of claims. Supports Office of the Chief Medical (OCMO), EH Clinical, Clinical Operations, Provider Reimbursement and operations teams as an enterprise lead analyst to define, design, develop, audit and implement coding schemes and reimbursement processes that enhance and problem solve configuration, new or inconsistent claim payment and coding policies. Act as a business owner to develop and document claims coding adjudication policies that includes engagement of strategic vendors or business partners. Maintain business decision support systems impacted by coding and payment policies through the cross-functional Reimbursement Policy Committee (RPC) and Reimbursement Policy Committee Workgroup (RPCW).
Lead clinical and reimbursement coordinator with vendors and medical policy teams to perform continuous claims reimbursement auditing.
Identifies and sponsors solutions of inconsistencies between CCI & EH reimbursement policies and claim payment through review of suspended and appealed claims and audits of related claim system(s) inputs, which directly impact claim payment (i.e. authorizations). And make recommendations to resolve inconsistencies.
Technical owner and content expert for procedure code editing software (Cotiviti / CXT), which includes customization of edits, coordination of testing of new releases with Information Services, and contact with the vendor for edit clarifications. Understands and resolves downstream impacts
Business content expert for clinical aspects and effectiveness of code editing software to ensure consistent and appropriate procedure code reimbursement, to maximize savings from claims incorrectly coded by providers.
Operations content expert for system versions of claims reimbursement and policy systems for testing and upgrades.
Provides direct education to employees and provider offices as needed to facilitate an understanding of correct claim coding, use of CPT4, ICD10, HCPCS, etc.
Supports training development as a subject matter expert / resource for internal staff tasked with development and delivery of training programs to facilitate an understanding of correct claim coding, use of CPT4, ICD-10, HCPCS, DRG, APC, etc.
Participates in RPC, RPCW, Medical Policy Committee (MPC) and Medical Policy Committee Workgroup (MPCW) to provide clinical policy representation at meetings, to ensure that decisions, which affect inputs to claim payments, are appropriate and will result in cost effective, efficient and accurate, claim reimbursement.
Operations owner and expert to process provider complaints and appeals including maintaining trends, Access database evaluating effectiveness of processes, and recommending changes for continuous improvement.
Write letters and other correspondence and communicates with vendors and providers as needed. Accountable for timely turnarounds of complaints/appeal resolution.
Tracks and reports statistics on Commercial and Medicare provider pends and appeals.
Performs review of all suspended and appealed claims requiring interpretation of clinical and pricing documentation (including but not limited to operative reports, office notes, system data) as it relates to the claim data, policies and standard CPT guidelines to provide consistent and fair reimbursement to providers.
Develop detailed coding instructions for EH/CCI medical policies on PA list
Responsible for maintaining PA grids, tech grids and HCPCS grids until a unified code set is established. At that time, the unified code set will be maintained by this position.
Provide updates on CMS changes and AMA / CPT changes and ensure implementation, as well as attending annual AMA code update meeting to understand all coding changes
Provides support for single case agreements with non-par providers.
Subject matter expert to coordinate with the Liability and Recovery unit through SIU Fraud Waste Abuse (FWA) investigative activities.
Participates with internal and external FWA work groups to identify and report new cases.
5 years of health insurance industry coding standards experience and certification required, (CPT, HCPCS and ICD10).
Prior experience in review of medical records required.
5 years of experience with management of claim editing software required.
5 years of experience in a managed care environment preferred.
3 years of experience in one of the following disciplines: Business analysis, Project management, Fraud and Abuse preferred.
Proficient in the use of Microsoft Office products ACCESS/Queries, WORD, POWERPOINT, EXCEL.
Technologically literate - familiar with IT focused systems and methodology (i.e., Cotiviti, ClaimXten, FAMS, AMISYS).
Applies Innovative, creative, \"out of the box\" thinking to problems.
Strong organizational, analytical, statistical and problem solving skills required.
Good oral and written communication skills required.
Strong business skills to interpret and monitor contract relationships.
Pay: 80-100K, based on experience
40/hrs a week
We know that a company's success starts with its employees. We also know that an individual's success starts with the right career opportunity. As a Best of Staffing Client and Talent leader, Aerotek's people-focused approach yields competitive advantage for our clients and rewarding careers for our contract employees. Since 1983, Aerotek has grown to become a leader in recruiting and staffing services. With more than 250 non-franchised offices, Aerotek's 8,000 internal employees serve more than 300,000 contract employees and 18,000 clients every year. Aerotek is an Allegis Group company, the global leader in talent solutions. Learn more at Aerotek.com.
The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please call 888-###-#### or email accommodation@aerotek .com for other accommodation options. However, if you have questions about this position, please contact the Recruiter located at the bottom of the job posting. The Recruiter is the sole point of contact for questions about this position.
Associated topics: biller, billing, clinical documentation specialist, collection, data entry, front, front desk, medical biller, medical coder, number