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Collects and analyzes data to evaluate operational obstacles which include revenue and compliance issues, and makes recommendations to resolve issues in a timely matter. Uses the medical classification system to design the benefit packages with proper ICD-9, CPT-4, HCPCS for configuration into the Peradigm System. Disseminates benefit determinations to key stakeholders administering benefits (health services, configurations, etc.) throughout the organization. Serves as an integral role in the testing, analysis and benefit configuration of new and existing plans.
Reviews, analyzes and translates diagnostic procedural phrases into coded form.
Updates and maintains adjudication system with defined code sets in logical order.
Coordinates with internal operations departments to ensure data accuracy.
Produces reports from the Peradigm System to analyze necessary modifications to codes sets, BRULES and MEDEFs.
Creates testing scripts for new and existing plans.
Assists in the on-going evaluation of the benefit configurations within the Peradigm System for new and existing benefit plans.
Documents the configuration of new plans as well as changes in existing plans.
Provides feedback to stakeholders regarding feasibility and requirements for enhancements to benefit configuration.
Provides research assistance for the resolutions of benefit issues.
Serves as a liaison of benefit configuration to external departments.
Collects and analyzes data to evaluate operational difficulties and makes recommendations to solve problems.
Performs special projects as needed.
Required An Associate's Degree in CIS, BIS, or coding
Required or equivalent work experience
Required 2 years of experience in medical coding and configuration
Intermediate Other Applies coding knowledge to ascertain codes sets for each service
Intermediate Other Ability to break procedures down at a granular level and organize data in a logical manner
Intermediate Other Ability to conduct Internet research to update code sets
Licenses and Certifications:
Preferred RMC certification
Required Intermediate Peradigm (Diamond)
Preferred Intermediate Microsoft Access
Preferred Intermediate SQL Server System
Required Intermediate Microsoft Word
Required Intermediate Microsoft Outlook
Preferred Intermediate Other Knowledge of organization of data within medical adjudication systems