Department: Operations - Payment Integrity
Reports to: Claims Coding Rules Supervisor
Escalation point for Operations Team assist with research, review and response to complex medical coding and payment policy inquiries. Perform in depth research of State and Federal Regulations, coding industry guidelines, and WellCare policy when evaluating existing and future edits as a result of inquiries and leads. Make recommendations for medical coding and payment policy edit changes based on clinical, financial and claims operations perspective. Supporting role for edit change implementation and problem solving. Subject matter expert on Medical Coding and Payment Policy for internal (corporate) and external (market and providers) partners. Ensures proper supporting documentation exists and is maintained on file for all processes.
Additional Responsibilities:Candidate Education:
- Receives, researches, and determines appropriate action steps to support Operations with handling complex medical coding and payment policy inquiries and/or disputes.
- Participates research of claims coding rule initiatives (expansion, MEI, Health Plan Policy, etc) including supporting the development, maintenance and execution of detailed project plans.
- Maintains a library of all 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 rule by Market and by Line of Business (Master Grid).
- Participate in cross-functional teams to address key claims coding rule issues facing the organization.
- Evaluates change proposal from a regulatory perspective, financial perspective, and claims operational perspectives.
- Makes recommendation for edit changes.
- Supports the edit change process.
- Identifies coding error (e.g., upcoding, bundling/unbundling) and recommends correct coding of medical claims.
- Researches CMS/State laws, WellCare policy and AMA guidance.
- Develops relationship with claims coding rule software vendors.
- Support corporate teams as necessary, inclusive of training in research and root cause.
- Perform other duties as assigned.
- Required A High School or GED
- Required 3 years of experience in medical coding field with a facility, provider or payer organization
Licenses and Certifications:
- Advanced Knowledge of medical terminology and/or experience with CPT and ICD-10 coding
- Intermediate Other Detail Orientation, understands big picture and captures relevant important information
- Intermediate Demonstrated written communication skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Beginner Demonstrated problem solving skills
- Beginner Demonstrated time management and priority setting skills
A license in one of the following is required:
- Required Other Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Or other relevant certifications
- Required Advanced Other Strong knowledge of electronic medical records/billing systems and medical terminology and abbreviations
- Required Advanced Other Billing expertise in UB04, CMS1500 and other healthcare services
- Preferred Advanced Other Knowledge of Encoderpro
- Required Beginner Microsoft Excel
- Required Beginner Microsoft Word
- Required Beginner Microsoft PowerPoint
- Preferred Intermediate Other Knowledge of one or more of the following: SQL, Xcelys, CES, iHealth or other claim editing software