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Corporate Functions & Operations WellCare - Coding & Records Careers

Coding Research - Manager Job

Full Job Title: Manager, Coding Research

Job Number: 1804136

Location: Tampa, FL

Date Posted: 2018-07-24

Location: Woodland Center Blvd, Tampa, FL 33634
Department: Operations - Payment Integrity
Reports to: Sr. Manager, Coding Integrity

Leads the corporate claims coding and payment rules function.

Essential Functions:
  • Function as the corporate authority regarding claim editing policy and procedure
  • Responsible for direct interaction with market leadership regarding all claims editing rules
  • Provide leadership and expertise in the development of potential new rules
  • Lead the coordination, validation and implementation of new rules
  • Perform routine and ad hoc financial impact analysis and reporting regarding effectiveness of rules
  • Manage support across the organization to PR, Customer Service, Claims and other areas as appropriate
  • Develop and manage the maintenance approach relative to coding issues and contractual arrangements
  • Manage dedicated payment policy team of policy research, implementation and provider resolution
  • Cross-functional interaction with Health Services regarding payment policy development activities and escalated claim issues
  • Routinely interface with coding experts and representatives regarding payment policy issues, rule justifications and rule changes
  • Maintain a library of all the existing and retired rules, the source of the rule, the implementation/retire date of the rule (by Market and by Line of Business) and other configuration-related decisions (e.g. provider exclusions) as necessary
  • Document supporting authority for payment policy by Market and by Line of Business (Master Grid)
  • Participate in cross-functional teams to address key claims coding issues facing the organization
  • Write and administer communication to Markets and collect feedback
  • Coordinate evaluation of change requests from clinical perspective, financial perspective, and claims operational perspectives; Prepare and present analysis of payment policy changes
  • Research CMS/State regulations, AMA and other professional organization guidance to support existing policy and implementation of potential new policy
  • Present change proposals to Claims Payment Policy Committee (CPPC)
  • Effective Market Communication
  • Develop and maintain relationship payment policy software vendors
  • Train organization (Claims, Customer Service, PR reps) on use of research tools
  • Perform other duties as assigned
    Candidate Education:
    • Required: Bachelor's Degree in a related field; or relevant managed care industry experience
    Candidate Experience:
    • Required: 5 years of experience in a health care payer/provider (hospital, multi-specialty physician, etc.) organization
    • Required: Experience working with health insurance claims payment systems and government payment systems
    • Preferred: Formal claims coding training and/or certification
    Candidate Skills:
    • Professional knowledge of medical terminology and abbreviations
    • Knowledge of Medicaid payment systems, including ability to quickly research and absorb new payment systems
      Technical Skills:
      • Billing expertise in UB04, 1500 and other healthcare services
      • Knowledge of Medicare payment systems and use of payment schedules, including: DRG, APC, Physician Fee Schedule, Lab Fee Schedule
      • Advanced user of payment rules engine

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        Last Updated On: 12/9/2015