Location:Work from home (Pennsylvania)Shift:Days (United States of America)Scheduled Weekly Hours:40Worker Type:RegularExemption Status:NoJob Summary:Supports overall efforts of the Medical Policy/Clinical Guidelines development area. Investigates and conducts audits of medical claims pursuant to changes in medical policy, and analysis of data to guide policy development and/or revision and makes recommendations to management. Conducts investigations and advises on the coverage status of claims based on current applicable medical policies, coding guidelines and industry information. Serves as a resource to assist staff with questions regarding medical policy implementation, coding, medical claims payment, claim edits and benefit set-up.Job Duties:

Experience with CPT coding, Medical Claims, Benefit Configuration preferred

• Provides direction to benefits systems analysts to assure correct configuration of benefits by line 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 to benefit coverage.
• Develops and maintains databases to catalog code status as related to medical policy, and state 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 Investigational or Unproven services.
• Makes presentations to various committees regarding the configuration of benefits and claims 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 workgroups 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.

Position Details:

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

Education:High School Diploma or Equivalent (GED)- (Required)Experience:Minimum of 2 years-Relevant experience* (Required)Certification(s) and License(s):Skills:Communication, Health Care Policy And Ethics Compliance, Leadership

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our family and our communities.

• KINDNESS: We strive to treat everyone as we would hope to be treated ourselves.
• EXCELLENCE: We treasure colleagues who humbly strive for excellence.
• LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow.
• INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
• SAFETY: We provide a safe environment for our patients and members and the family.

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.