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Corporate Functions & Operations WellCare - Claims Careers

Claims Coding Specialist Job

Full Job Title: Claims Coding Specialist

Job Number: 1806646

Location: Tampa, FL

Date Posted: 2018-09-13

Position is primarily responsible for reviewing, researching, and responding to written and emailed correspondence from providers, both professional and institutional, regarding claim denials based on clinical coding policies. Acts as a subject matter expert and handles more complex provider issues.

Essential Functions:
  • Reviews and responds to written provider disputes, clearly and articulately outlining the payment discrepancy to the provider.
  • Thoroughly researches post payment claims and takes appropriate action to resolve identified issues within turnaround time requirements and quality standards.
  • Navigate CMS and State specific websites, as well as AMA guidelines, and compare to current payment policy configuration in order to resolve the providers payment discrepancy.
  • Review medical records to ensure coding is consistent with the services billed and compares against the clinical coding guidelines in order to decide if a claim adjustment is necessary.
  • Processes claim adjustment requests in Xcelys following all established adjustment and claim processing guidelines.
  • Utilize SharePoint and Excel as necessary to work through daily inventory assignments.
  • Identifies and escalates root cause issues to supervisor for escalated review.
  • Reviews and responds to internal escalated provider disputes transferred by management and other associates.
  • Acts as liaison with other departments when additional clarification is needed about claims payment policy disputes.
  • Assists team members with training opportunities and coaching.
  • Assists with special projects as assigned or directed.
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    Candidate Experience:
    • Required 3 years of experience in claim coding, claim processing or billing in a healthcare environment
    • Preferred 1 year of experience in claims coding
    Candidate Skills:
    • Intermediate Demonstrated written communication skills
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Advanced Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
    • Intermediate Other Ability to quickly research and absorb new payment systems
    • Intermediate Other Knowledge of Medicare and Medicaid payment systems
    Licenses and Certifications:
    • Preferred CPC, CSS or relevant certifications
    Technical Skills:
    • Required Intermediate Other Strong knowledge of electronic medical records/billing systems and medical terminology and abbreviations
    • Required Intermediate Other Billing expertise in UB92, UB04, HCFA 1500 and/or other healthcare services

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      Last Updated On: 12/9/2015