Responsibilities

• Annually and quarterly review and research, as necessary, all new Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes for coding logic, related Medicare policies, and rate information to enable the Chief Medical Officer to make coverage and reimbursement determinations

• Perform comprehensive maintenance review on all Fund policies, HCPCS codes, Molecular Pathology and

Proprietary Laboratory Analyses codes, Vaccine codes, Contraceptives/IUD codes and Radiopharmaceuticals which involves examining the codes to modernize coding reimbursement policies inclusive of coding regulations and coding configuration

• Develop enhanced, customized prospective claims auditing and clinical coding and reimbursement policies, and the necessary coding configuration for Lyric’s Policy Management Module (PMM). At least annually monitor, manage, measure, and analyze and report outcome results of the policies. Develop documents as necessary

• Utilize statistical data to examine large claims data sets to provide analyses and reports on existing provider billing patterns as compared to industry standard coding regulations; and make recommendations based on industry standard coding logic, business rules and Fund policy

• Perform complex compliance claims audits or clinical reviews on pended claims to investigate, research, and analyze CPT and HCPCS claims data. When indicated, identify errors, wasteful/excessive billing practices on a claim, provider and/or code level. This includes trouble shooting, resolving issue(s) and/or recommending corrective action for deficiencies, irregularities, and anomalies. Requires interpretation of industry standard health care coding conventions and Fund contracts / policies.

• Perform timely review and payment/denial recommendations for claims on the daily Professional Active Codes Without Rate Report and for claim inquiries/appeals submitted via e-mail and the Funds’ Document Management System (DMS). Address coding issues submitted by Provider Relations specific to provider type/specialty.

• Collaborate with different departments to define the Benefit Fund’s policy criteria according to current and standard clinical coding rules/logic. Interact with the medical claims processing program’s (QNXT) production department to perform pre and post testing.

• Use and maintain the rules and Fund policies in Lyric, the Fund’s advanced claim auditing software application. This prospective application interfaces with a claims adjudication system to help ensure that the Fund’s clinical coding and claim editing logic are accurate and consistent with industry standard guidelines to ensure that claims are processed efficiently, and providers are reimbursed accurately. Provide direction to the configuration team for required new edits and revisions to existing rules and Management Policies (MPs). Test the configurations which includes auditing, interpreting, and reporting the results to determine if the edits are being applied correctly. This is an interdependent team approach with the configuration/production team

• Work closely with management to develop manage and update operating procedures or other relevant documentation for program specific data management activities; monitor operational activities to ensure compliance with documented policies, procedures standards and quality improvement processes. Generate timely reports, analyze and summarize cost savings reports, track and trend outcomes and recommend custom solutions for all clinical compliance initiatives

• Craft user manuals, policy, procedures, or other pertinent documentation to support clinical compliance initiatives

• Train staff as necessary

• Design and conduct quality control and improvement activities (utility of software applications, report generation, test scenario development, check report results for quality, claims auditing, etc.), track and trends results, and recommend corrective action for problems, irregularities and anomalies

• Perform additional duties and projects as assigned by management

Qualifications

• Bachelor’s degree in health care or related field or equivalent years of work experience required

• Minimum five (5) years senior level, progressive experience in medical outpatient claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required

• Direct and relevant experience with professional/HCFA 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) 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.)

• AAPC (formerly the American Academy of Professional Coders) Certified Professional Coder (CPC®) or the American Health Information Management Association (AHIMA) Certified Coding Specialist – Physician-Based (CCS-P®) credential required. AAPC Certified Outpatient Coder (COC®0 or AHIMA Certified Coding Specialist (CCS®) credential is a plus

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

• Advanced skill level in Microsoft Word and Excel required

• Intermediate level experience with Lyric claims auditing software programs preferred

• Solid aptitude in math with frequent use of calculation functions