Medical Policy Implementation Specialist, Health Plan; Eastern Standard Time Zone resident

Experience with
CPT coding, Medical Claims, Benefit Configuration preferred

• Provides direction to benefits systems analysts to assure correct configuration of benefits byline of business and maintains the repositories for code configuration changes as a result of medical policy development and government directives.
• Conducts research and retrospective review of medical claims in an attempt to determine and ensure compliance with contractual, state and federal regulations.
• Completes requests for and reviews of medical records to validate services billed to the medical benefit with unlisted or miscellaneous codes.
• Research reimbursement, medical record documentation, utilization and proper coding.
• Reviews clinical documentation to determine eligibility of coverage.
• Makes recommendations to system set up for proper claims adjudication with regard tobenefit coverage.
• Develops and maintains databases to catalog code status as related to medical policy, andstate or federal mandates.
• Maintains and manages coding matrix and databases associated with contracted vendors,prior authorization requirements, Preventive Services, non-covered services and Experimental and Investigationalor Unproven services.
• Makes presentations to various committees regarding the configuration of benefits andclaims to support medical policy development initiatives.
• Produces ad hoc reporting to determine pre- and post-implementation utilization trends
• Identifies operational deficiencies and areas where process improvement would decrease the company's exposure with regard to medical claims payment as it relates to benefits, coverage and financial liability.
• Investigates and conducts audits of medical claims, analyzes data, to guide policy development and revision and reporting capability.
• Conducts review and coordinates multi-departmental implementation of annual new codes,quarterly updates and assigns new coding to treatment types which assures appropriate cost-sharing tiers.
• Continually audits claims and ensures compliance with current coding guidelines and industry information utilizing Health Plan policies.
• Addresses claims payment errors as revealed through claims audit and retrospective review.
• Process claims in Facets workflow that pend for medical policy implementation specialist manual review.
• Reviews claim research request forms (CRRF) for claim adjustment determination.
• Acts as resource for CPT/HCPCS code advisement to various GHP work groups ad hoc.
• Participates in standing GHP operational meetings as needed.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

* Relevant experience may be a combination of related work experience and degree obtained (Associate’s Degree = 2 years; Bachelor’s Degree = 4 years).