Coding Research Analyst

Location: W Idlewild Ave, Tampa, FL 33634

Reports to: Supervisor, Claims Coding Rules

Department: Operations - Payment Integrity

Manages claims coding rule process. Evaluates claims coding rule change request from clinical, financial, and claims operations perspectives. Provides regulatory and correct coding research on change requests and makes recommendations on correct payment policy and edit functionality. Defines requirements and partners with Business Analysts throughout testing and implementation. Manages the external Provider Dispute Process, supporting the front line Provider Resolution Team, evaluating escalated disputes and supporting the Medical Director review process.

Essential Functions:

  • Manages the external Provider Dispute Process by researching and evaluating escalated disputes and supporting the Medical Director review process.
  • Manages research of claims coding rule initiatives including the development of detail work plans.
  • Receives and logs requests of changes and appeals to committees ruling.
  • Maintains a library of all the existing and retired rules, the source of the rule and the implementation/retire date of the rule (by Market and by Line of Business).
  • Documents supporting authority for each claim coding rules by Market and by Line of Business (Master Grid).
  • Participate in cross-functional teams to address key claims coding rule issues facing the organization.
  • Administers communication to Markets and collects feedback.
  • Evaluates change proposal from a regulatory perspective, financial perspective, and claims operational perspectives.
  • Seeks professional feedback from Health Services, Finance, and Claims on claims coding rule changes.
  • Identifies coding error (e.g., upcoding, bundling/unbundling) and recommends correct coding of medical claims.
  • Researches CMS/State laws and AMA guidance.
  • Presents change proposal to committee.
  • Communicates effectively to markets.
  • Develops relationship with claims coding rule software vendors.
  • Receives, researches, and determines appropriate action steps for escalated provider disputes from Correspondence, PRT, Claims, and the Markets.
  • Trains and/or provides guidance to Claims Coding staff.
  • Support claims, configuration, PRT, and/or appeal & grievances teams as necessary.
  • Perform other duties as assigned.
Candidate Education:
  • Preferred: Associate's Degree in a related field
Candidate Experience:
  • Required: 4 years of experience in medical coding field with a facility, provider or payer organization
Candidate Skills:
  • Demonstrated written communication skills
  • Demonstrated leadership skills
  • Demonstrated interpersonal/verbal communication skills
  • Ability to work as part of a team
  • Demonstrated problem solving skills

Licenses and Certifications:
A license in one of the following is required:

  • Registered Health Information Administrator (RHIA)
  • Registered Health Information Technician (RHIT)
  • Certified Coding Specialist (CCS)

Technical Skills:

  • Microsoft PowerPoint
  • Microsoft Excel
  • Microsoft Word
  • Knowledge of CMS/State laws and AMA guidance
  • Advanced user and knowledge of claims payment system
  • Knowledge of 3M Encoder
  • Strong knowledge of electronic medical records/billing systems and medical terminology and abbreviations
  • Billing expertise in UB92, 1500 and other healthcare services


About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.