Resp & Qualifications

PURPOSE: 
Acts as an internal expert to ensure that reimbursement and medical policy guidelines are adhered to. Provides expert knowledge to support effective guidance on the appropriate quality measure capture and proper use of CPT and ICD 10 codes in claims submissions. Utilizes coding expertise, combined with medical policy, credentialing, and claim processing rules knowledge to determine appropriate billing and code submissions while not compromising payment integrity. Provides expertise and mentoring to other team members. 

ESSENTIAL FUNCTIONS:

• Consults on proper coding rules to ensure appropriate and proper use of CPT and ICD10 codes. Provides expertise on various consequences for different financial and incentive models. Strategizes alternatives and solutions to maximize payments and risk adjustment. Translates from claim language to services in an episode or capitated payment to articulate inclusions and exclusions in models.
• Serves as a technical resource / coding subject matter expert for SIU related issues. Conducts complex business and operational analyses to assure payments are in compliance with contract; identifies areas for improvement and clarification for better operational efficiency. Provides problem solving expertise on systems issues if a code is not accepted. Troubleshoots, make recommendations and answer questions on more complex coding and billing issues whether systemic or one-off.
• Supports and contributes to the development and refinement of effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality outcomes while not compromising payment integrity. May interface directly with provider groups during proactive training events or just in time on complex claims matters. Consults with various teams including, medical policy and colleagues to interpret coding and documentation language and respond to inquiries from providers.
• Keeps up to date on coding rules and standards. 

QUALIFICATIONS:

Education Level: High School Diploma or GED.

Licenses/Certifications Required Upon Hire:

• CCS-Certified Coding Specialist or
• Certified Coder (CCS or CPC)-AHIMA or AAPC 

Experience: 3 years experience in risk adjustment coding, ambulatory coding and/or CRC coding experience in managed care; state or federal health care programs; or health insurance industry experience.

Preferred Qualifications:

• Bachelor's degree in related discipline.
• Experience in medical auditing.
• Experience in training/education/presenting to large groups.
• Experience in revenue cycle management and value-based reimbursement/contracting models and methodologies.

Knowledge, Skills and Abilities (KSAs)

• Knowledge of billing practices for hospitals, physicians and/or ancillary providers as well as
• knowledge about contracting and claims processing.
• Knowledge and understanding of medical terminology to address codes and procedures.
• Excellent communication skills both written and verbal.
• Detail oriented with an ability to manage multiple projects simultaneously.
• Demonstrated ability to effectively analyze and present data.
• Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and demonstrated ability to learn/adapt to computer-based tracking and data collection tools.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
  
  

Salary Range: $53,928 - $107,107

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