It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

The Regulatory and Transaction Coding Manager is responsible for managing all aspects of claims based HIPAA code sets and cross-departmental implementation of billing code sets utilized in healthcare transactions for the plan. This individual will closely monitor reimbursement regulations and industry policy changes from HIPAA, Medicare & Medicaid, Official Coding & Reporting Guidelines, National Correct Coding and Industry coding standards to ensure all ancillary systems are aligned.

The Regulatory and Transaction Coding Manager will be responsible for developing SOPs-standard operating procedures, lead system data audits, reconcile coding gaps, create new business processes/workflows, business and technical requirements and will lead cross-departmental review, operational assessment and implementation efforts to ensure timely and accurate completion of reimbursement regulatory and coding changes.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/Responsibilities:

• Develops and maintains corporate transaction policies, and works collaboratively with stakeholders and department manager to ensure consistency with the Plan's system(s)
• Monitors sites and regulation governing healthcare transaction data to include AMA, CMS, NUBC, UB Editor, WPC DHHS, EOHHS, and, listservs and other sources to identify existing coding & payment practice and upcoming changes
• Determine the scope and impact of the change on Plan operations and seek to implement changes as necessary
• Ensures all code sets stored in the Plan's transaction processing system are accurate and up-to-date
• Responsible for requirements development, follow through and testing support on end-to-end implementation of coding updates across all systems
• Act as an SME, support and responds to all code set inquiries and discrepancies
• Responsible for obtaining electronic copies of all code sets and facilitating required system updates to ensure continued HIPAA compliance
• Monitors and resolves claim processing errors related to code validation edits during adjudication
• Provides industry interpretive expertise in the evaluation of regulatory, coding and transaction based business rules
• Staff and participate in various work groups and committees to support coding policies and provides input into processes and workflows reliant on code based policy outcomes
• Serve as the department's project manager for: (1) regulatory information such as proposed and final Medicare and/or Medicaid reimbursement and coding regulations, Medicare Manual code updates, DHHS and EOHHS transaction code changes
• Determine the scope and impact of the information/issues and take appropriate action
• Collaborate with Public Partnerships, Contracting, Finance, Provider Relations, Product Administration, Configuration, and Provider Audit/OPL to determine the impact of implementing recommended policy changes
• Develop project plans including: setting timelines and deliverables; determining resource requirements; documents decisions; draft communication plan; information-sharing with appropriate staff and seek approval from Governance; and subsequently ensure successful completion of change
• Serve as the company's research specialist regarding industry standard code set policies
• Submits recommendations to the Payment Policy Committee and supports Committee efforts through subgroups and individually as needed
• Collaborate with stakeholder departments to develop and maintain a database to serve a centralized location to store coding truth source information
• Key point of contact for Configuration analysts on testing and use of correct coding to ensure proper configuration ensued
• Assist configuration analysts on all requests; i.e. modifier and revenue code combinations
• Key point of contact for outside departments: Claims, Provider Relations, Customer Care, and Contracting; researches all requests triggered from coding denials and potential configuration issues

Qualifications:

Education:

• AHIMA or other nationally recognized Coding Certification
• Bachelor's Degree in a related field or the equivalent combination of training and experience
• Master's Degree or graduate work in a related field preferred
• Coding Certification for Payers - CPC-P preferred

Experience:

• 8 or more years' experience in a fast paced, managed healthcare environment is required
• At least 6 years direct work in claims processing, payment policy, or contracting
• Extensive background of ICD-10 and CPT coding principles
• Extensive knowledge of medical claim editing (NCCI, etc.)
• Knowledge of industry standard payment rules and methods
• Knowledge of Medicare, Medicaid and commercial coding rules/ regulatory requirements
• Ability to clearly communicate very complex coding and reimbursement terms to business units
• Medical chart auditing preferred

Competencies, Skills, and Attributes:

• Demonstrated proficiency in coding and knowledge of the requirements of industry standards such as Medicare and/or Managed care regulations required
• Strong understanding of HIPAA Guidelines
• Good communication skills, both oral and written, ability to interact well with others at all levels, strong organizational skills, strong customer service skills and orientation
• Expertise utilizing Microsoft Office products, primarily Microsoft Word and Excel
• Knowledge of Optum CES product, or similar claims editing system

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.