Location: Idlewild Ave, Tampa, FL
Reporting to: Supv, Claims Coding Rules
Position is primarily responsible for reviewing, researching, and responding to written and emailed correspondence from professional and institutional providers as well as telephonic inquiries from providers and members regarding claim denials based on clinical coding and payment policies. Also serves as the departmental liaison for Field Magic and provider relations. Acts as a subject matter expert for internal (corporate) and external (market and providers) partners.
Additional Responsibilities:Candidate Education:
- Reviews and responds to written and telephonic 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 system following all established adjustment and claim processing guidelines.
- Utilize SharePoint and Excel as necessary to work through daily inventory assignments.
- Identifies and recommends modifications to payment policies once root cause has been established and works with team leadership to implement changes and communicate modifications to the team.
- Reviews and responds to internal escalated provider disputes transferred by management and other associates.
- Acts as liaison with other departments and external market and providers when additional clarification is needed about claims payment policy disputes. Coordinate evaluation of change requests from clinical, financial and claims operation perspective.
- Participate in calls with market representatives and team leadership to work through complex provider disputes and payment policy interpretation disputes.
- Assists with reviewing root causing audit errors.
- Work with IT or operations to determine root cause of errors on vendor report.
- Assists team members with training opportunities and coaching, including producing team communications regarding how to research/root cause.
- Assists with special projects as assigned or directed.
- Required A High School or GED
- Required 4 years of experience in claim coding, claim processing or billing in a healthcare environment
- Required 1 year of experience in claims coding
Licenses and Certifications:
- 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
- Preferred CPC, CSS or relevant certifications
- Required Advanced Other Strong knowledge of electronic medical records/billing systems and medical terminology and abbreviations
- Required Advanced Other Billing expertise in UB92, UB04, HCFA 1500 and other healthcare services