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Residency in or relocation to Louisiana is preferred for all positions.

POSITION PURPOSE

This position serves as the medical coding expert on CPT, HCPCS, ICD-10-CM, and CDT coding for internal and external customer service requests, coding updates, education, and complex expert testimony. Partners with Configuration Administrator on department systems and projects, serves as the primary editor for multiple systems, overseeing the most difficult and costly changes.

NATURE AND SCOPE

• This role does not manage people

• This role reports to this job: Manager, Medical Coding

• Necessary Contacts: In order to effectively fulfill this position the incumbent must be in contact with:Medical Directors, departmental management in Provider Reimbursement, Provider Audit, Medical Management, I.T., BCBSLA Network physicians, national physician specialty organizations, American Medical Association, Centers for Medicare and Medicaid Services (CMS/HCFA), Louisiana Medicare and American Academy of Professional Coders.

QUALIFICATIONS

Education

• Bachelor's in health information management, healthcare or a related field is required.

• An RN license can be used In lieu of a Bachelor’s degree.

• Four years of related medical coding experience with demonstrated understanding of anatomy, physiology and medical terminology can be used in lieu of a Bachelor's degree.

Work Experience

• 6 years of current hands-on consultant-level expertise with in-depth research, analysis and application of CPT, HCPCS, and ICD-10-CM coding, billing and reimbursement guidelines for Medicare and private payers required

• Requires extensive experience with provider billing practices, American Medical Association coding guidelines, Correct Coding Initiative edits, Physician Specialty guidelines, payor reimbursement programs, claims adjudication processes, and regulatory agency policies (CMS/HCFA).

• Prefer experience editing multiple systems and consulting with technical staff on configuration.

Skills and Abilities

• Requires a strong body of knowledge regarding disease processes and medical and surgical procedures.

• Requires analytical skills, supported by critical thinking skills, and an understanding of all aspects of healthcare financing and institutional reimbursement, including industry-wide (private and governmental) payment methodologies.

• Requires strong oral and written communication skills and ability to facilitate internal strategic operational discussions.

• Understanding of project management skills regarding project planning and implementation.

• Knowledge of Microsoft Office products including Word, Excel and Power Point. Work experience must demonstrate the ability to work proficiently in a fast-paced demanding environment.

• May have to travel overnight one to two times a year.

• Licenses and Certifications

• Certified professional coding credentials for CPT, HCPCS, and ICD-10-CM medical coding systems is required

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

• Provides written medical coding expert-level responses to internal and external customer requests (provider appeals) for clarification of medical coding issues, clinical editor bundling and filtering, medical coding policy, regulatory agency policy and coding-related reimbursement and medical policy issues, in a prompt and efficient manner to support medical coding-related activities at BCBSLA.

• Provides expert testimony on behalf of BCBSLA for medical coding-related issues and serves as the chief medical coding resource for the Medical Director, Medical Coding Committee, Medical Policy Implementation Committee, Financial Investigations, Provider Reimbursement, Provider Audit, Provider Relations, Network Development, I.T., Medical Management, Actuarial and Medical Coding in a prompt and efficient manner to support medical coding related activities at BCBSLA.

• Develops and coordinates development of customized code lists, including code updates and crosswalks for BCBSLA mainframe system edits, clinical editor customizations, medical policy implementations, reimbursement program development, medical coding audits, departmental research and projects in a prompt and efficient manner to support medical coding-related activities at BCBSLA.

• Makes formal and informal presentations on medical coding issues to internal and external customers of BCBSLA to provide continuing education and to clarify medical coding-related processes at BCBSLA.

• Assists in the training and development of less experienced staff.

• Assist in efforts with the Medical Coding Department to incorporate quarterly and annual new medical code revisions into reimbursement systems and strategies. Ensures that all new CPT/HCPC codes, etc, are incorporated into all applicable reimbursement programs by the required dates to prevent the related provider claims from paying more than the appropriate, contracted reimbursement. Also ensures that the semi-annual fee updates for new CPT/HCPCS codes are implemented by the established deadlines.

• Assist with the configuration, implementation, maintenance and documentation of Payment management systems including the clinical editing requirements and the application of medical policy.

• Assist with the research and resolution of payment management system coding issues which are identified by various departments as a result of claims processing discrepancies and/or provider disputes.

• Ensures compliance with BCA mandates, DOI mandates, new applicable state and federal laws/regulations, and claims editing rules.

Additional Accountabilities and Essential Functions

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

• Perform other job-related duties as assigned, within your scope of responsibilities.

• Job duties are performed in a normal and clean office environment with normal noise levels.

• Work is predominately done while standing or sitting.

• The ability to comprehend, document, calculate, visualize, and analyze are required.

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An Equal Opportunity Employer

All BCBSLA EMPLOYEES please apply through Workday Careers.

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Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.

In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.

JOB CATEGORY: Insurance