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Research and prepare benefit files using industry standard codes that meet the intent of the benefit language for internal documents such as; Medicaid & Medicare Provider Manual, Evidence of Coverage documents, legislative (state and federal) mandates, Summary of Benefits or other health plan documents.
Research and respond to support benefit intent questions during plan design. Provides Product and Benefit support as required for the development of payment or medical polices when there are impacts to benefits.
Provide problem management recommendations on correct application of benefits intent based on industry and internal research.
Provide recommendations to internal and external customers as coding subject matter expert.
Perform updates to the internal software/ applications for benefits as needed.
Complete regular updates to Benefit Policies as changes occur.
Support testing to verify benefit coding performs as designed.
Bachelors degree required.
AHIMA Certified CCS or CSS-P required.
Generally requires 5-8 years of directly related professional experience and possesses deep technical abilities.
Work history in one or more of the following:
o 3 years of Provider billing experience in a lead, supervisory or management role or;
o 2 years in a payor environment working directly with payment quality and accuracy in a claims processing, provider contracting or audit capacity or; 2 years in a compliance or audit function within a healthcare system.
Functions well in an environment where delivery on time-sensitive projects is required.
Ability to lead cross-functional meetings to achieve cross-functional alignment.
Strong level research and analytical skills into industry and internal sources.
Broad, but not in-depth knowledge of payor claims processing systems, benefits, facility and physician contracts and medical and payment policy.
Working knowledge of provider billing practices and standards, including in-depth knowledge of HCFA 1500 and UB-04 claims data.
Some knowledge of Health Care Reform/ACA mandate requirements.
Strong writing and communication skills.
Able to independently use Microsoft Office products (Excel, Word, Outlook, Access, SharePoint).