Senior Medical Coding Specialist; Remote

Position: Senior Medical Coding Specialist (Remote)
Resp & Qualifications

PURPOSE:

The Senior Medical Coding Specialist acts as an internal expert to ensure that value-based reimbursement and medical policy models are developed and implemented to support Payment Integrity. This role provides expert knowledge to support effective partnership with provider entities, guidance on the appropriate quality measure capture and proper use of CPT and ICD 10 codes in claims submissions. This role utilizes coding expertise, combined with medical policy, credentialing, and contracting rules knowledge, to build effective guidelines and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity.

This role will also provide expertise and mentoring to other team members. This role will sit within the Payment Integrity team.

ESSENTIAL FUNCTIONS:

* Consults on proper coding rules in value-based contracts to ensure appropriate quality measure capture and proper use of CPT and ICD
10 codes. Provides expertise on various consequences for different financial and incentive models. Strategizes alternatives and solutions to maximize quality 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 contract pricing 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.

* Develops and refines effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs 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 the Practice Transformation Consultants, Medical Policy Analysts and Provider Networks colleagues to interpret coding and documentation language and respond to inquiries from providers.

* Participates in strategy and contributes to thought leadership for quality measure capture (NCQA, HEDIS, STARs). Collaborates with internal stakeholders on process and outcome improvement activities. Ensure compliance with all coding standards.

* Facilitates mentorship, providing assistance to less seasoned team members.

* Actively researches industry trends, keeping up-to-date and maintaining a high level of expertise in coding rules and standards.

SUPERVISORY RESPONSIBILITY:

Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.

Education Level: Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications Upon Hire

Required:

* CCS-Certified Coding Specialist or

* Certified Coder (CCS or CPC)-AHIMA or AAPC

Experience:

5 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:

* Certified public accountant

* Experience in medical auditing

* Experience in training/education/presenting to large groups

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.

* Experience in revenue cycle management and value-based reimbursement/contracting models and methodologies.

* Detail-oriented with an ability to manage multiple projects simultaneously.

* Excellent communication skills both written and verbal.

* Demonstrated ability to effectively analyze and present data.

*…