Why This Role is Important to Us:

Position Summary:

Working under the direction of the Sr. Director, TPA Management and Claims Compliance, Healthcare Medical Claims Coding Sr. Analyst will be responsible for developing prospective claims auditing and clinical coding and reimbursement edits and necessary coding configuration requirements for Optum CES and Zelis edits. This role will ensure that the applicable edits are compliant with applicable Medicare and Massachusetts Medicaid regulations. The role will also be responsible for timely review and research, as necessary on all new and revised coding logic, related Medicare/Medicaid policies for review/approval through the Payment Integrity governance process.

Supervision Exercised:

• No, this position does not have direct reports.

What You'll Be Doing:

Essential Duties & Responsibilities:

• Develop enhanced, customized prospective claims auditing and clinical coding and reimbursement policies and necessary coding configuration requirements for Optum CES and Zelis edits.

• Quarterly and Annual review and research, as necessary on all new CPT and HCPCS codes for coding logic, related Medicare/Medicaid policies to make recommend reimbursement determinations.

• Analyze, measure, manage, and report outcome results on edits implemented.

• Utilize data to examine large claims data sets to provide analysis and reports on existing provider billing patterns as compared to industry standard coding regulations, and make recommendations based on new/revised coding edits for presentation to Payment Integrity committee meetings.

• Analyze, measure, manage, and report outcome results on edits implemented.

• Use and maintain the rules and policies specific to CES and Zelis.

• Query and analyze claims to address any negative editing impacts and create new opportunities for savings based on provider billing trends

• Liaison between business partners and vendors; bringing and interpreting business requests, providing solutioning options and documentation, developing new policies based on State and Federal requirements, host meetings, and managing projects to completion

• Define business requests received, narrow the scope of the request based on business needs and requirements, provider resolution option based on financial ability and forecasting for small to large Operations Management

• Collaborate system and data configuration into CES (Claims Editing System) with BPaaS vendor and other PI partners, perform user acceptance testing, and analyze post production reports for issues

• Support collaboration between PI/Claims and other internal stakeholders related to the identification and implementation of cost-savings initiatives specific to edits.

Working Conditions:

• Standard office conditions. Remote opportunity.

Other:

• Standard office equipment

• None/stationary

What We're Looking For:

Required Education (must have):

• Bachelor's Degree or Equivalent experience

Ideal Candidate to have the one or all of the required certification OR willing to get certified within 1 year of employment --

• Certified Professional Coder (CPC)

• Certified Inpatient Coder (CIC)

• Certified Professional Medical Auditor (CPMA)

Desired Education (nice to have):

• Masters Degree

Required Experience (must have):

• 7+ years of Healthcare experience, specific to Medicare and Medicaid

• 7+ years progressive experience in medical claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required

• 7+ years experience with Optum Claims Editing System (CES), Zelis, Lyric or other editing tools

• Extensive knowledge and experience in Healhcare Revenue Integrity, Payment Integrity, and Analytics

• 5+ years of Facets Claims Processing System

Required Knowledge, Skills & Abilities (must have):

• Knowledge and experience of claim operations, health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare)

• Medical Coding, Compliance, Payment Integrity and Analytics

• Direct and relevant experience with HCFA/UB-04 claims management, coding rules and guidelines, and evaluating/analyzing claim outcome results for accurate industry standard coding logic and policies (i.e . Center for Medicare & Medicaid Services (CMS) & MA Medicaid, Correct Coding Initiative (CCI), Medically Unlikely Edits (MUEs) both practitioner and facility, modifier to procedure validation, and other CMS and American Medical Association (AMA) guidelines, etc.)

• Advanced experience of medical terminology and medical coding (CPT, HCPCS, Modifiers) along with the application of Medicare/Massachusetts Medicaid claims' processing policies, coding principals and payment methodologies

• Ability to work cross functionally to set priorities, build partnerships, meet internal customer needs, and obtain support for department initiatives

• Ability to plan, organize, and manage own work; set priorities and measure performance against established benchmarks

• Ability to communicate and work effectively at multiple levels within the company

• Customer service orientation; positive outlook, self-motivated and able to motivate others

• Strong work ethic; able to solve problems and overcome challenges

Required Language (must have):

• English

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.