Job Description
- Job Description:
- Provide clinical leadership and subject-matter expertise to support the analysis, configuration, and administration of complex medical policy content within claims processing systems, including Plan General Exclusion (PGE) rules and FACETS table maintenance.
- Ensure the accurate implementation of medical policies, review criteria, and authorization requirements, while maintaining the integrity of system infrastructure.
- Serve as a key liaison between business and technical teams.
- Research and analyze system and business issues, develop high-level requirements, test and implement solutions, and audit and document outcomes.
- Serve as an expert resource for medical policy configuration and PGE coding, mentoring and training Coding Specialists, and providing policy-related training and support to operational partners such as customer and provider services.
- Must be willing to work core business hours of 8 AM - 5 PM Central Time.
- Requirements:
- Associate degree or direct and applicable work experience preferred.
- Certified Professional Coder (CPC) required.
- Clinical background which may include either formal education or training in a clinical or health-related discipline (such as nursing, medical assisting, surgical technology, health information management, or a related field) and/or direct work experience in a clinical or healthcare setting.
- 7+ years’ or related health care experience in provider payment, claims, medical coding, or similar.
- Demonstrated expertise and knowledge of medical coding and terminology.
- Demonstrated strong attention to detail with the ability to multitask.
- Strong interpersonal skills including clear and concise written and verbal communication.
- Inquisitive nature, enthusiastic about developing and enacting new processes.
- Strong workflow management skills with sense of ownership, drive and initiative to continuously improve outcomes.
- Ability to communicate concepts clearly and concisely to individuals and groups and motivate others to achieve success with an eye toward promoting a culture of collegiality and excellence.
- Demonstrated ability to obtain relevant information by relating and comparing data from different sources.
- Proficiency in Microsoft Office applications including experience with spreadsheets, process mapping, presentation and word processing.
- Ability to adhere to quality and production metrics.
- Some experience with and continued interest in coaching and mentoring others.
- Demonstrated ability to consistently meet department work schedule.
- Benefits:
- Health Services Coding Analyst (CPC Required)
- Remote Eligible
- Great to have: Prior health plan experience.
- Must provide high-speed internet.
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