Location: Tampa, FL or Telecommute
Department: Operations - Payment Integrity
Reports to: Sr. Manager, Coding 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.
- 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.