The Provider(Coding) Reimburse Admin ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria.
- Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducts clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.
- Translates medical policies into reimbursement rules. Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits.
- Coordinates research and responds to system inquiries and appeals.
- Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.
- Performs pre-adjudication claims reviews to ensure proper coding was used.
- Prepares correspondence to providers regarding coding and fee schedule updates.
- EM Leveling audit experience.
- Experience working in a production environment with short timelines is strongly preferred.
- BA/BS degree; 2-3 years related experience; or any combination of education and experience, which would provide an equivalent background.
- Time Management skills is essential.
- Requires a current American Academy of Professional Coders (AAPC) CPC or American Health Information Management Association (AHIMA): RHIA, RHIT, CCS, CCS-P coding certification.
- Medicaid Commercial business products knowledge/experience a plus.
- WGS and FACETS experience preferred.
- Proficiency in Microsoft Word, Excel and SharePoint preferred.
Vacancy Type: Full Time
Job Location: Lynchburg, VA, US
Application Deadline: N/A