at Signature Performance, Inc. in Portland, Maine, United States
This is a remote based position. Applicants can be located nationwide
Medical Policy Business Analyst/ ClaimsXM Coding Consultant
Who We Are:
Signature Performance is working hard at lowering healthcare administrative costs for federal government agencies, payers, and providers. At Signature, our mission is to improve the health of our clients' business and making the lives of the people we work with better. We do that by leading with our values of Passion, Courage, Integrity and Respect in all interactions.
What We Offer:
Signature believes in fully developing each one of our Associates. We deliver a performance-driven atmosphere with competitive pay and bonus structure, world-class training and development classes, resources, and events, an award-winning culture to thrive in, and so much more.
Tuition Assistance Program
401(k) program with employer contributions
Comprehensive health insurance
Competitive Paid Time Off for Sick and Vacation Time
No-cost annual flu shots
A hybrid work-from-home and/or on-campus work plan
We are happy to be adding a new member to our team! As an HIM Consultant, your main responsibility is the verification that our system is properly adjudicating claims. You will do this through the review of adjudicated claims, how workflow was applied, how policy and edits were applied, how pricing was applied, how COB was handled, etc. Primarily, you will be responsible for reviewing a UB04/CMS1500 and determining what is missing or what is wrong with the claim. Additionally, you will be responsible for medical policy compliance-related initiatives and projects, including the development of a proactive monitoring program for changes in laws, regulations and policy guidance affecting our client's medical policies. This work will be multi-faceted requiring complex regulatory analysis and interpretation, extensive consultation with our client Policy and Benefit colleagues, and the integration of project outcomes into the medical policy development process.
Other responsibilities may include:
Will support the building, reviewing, testing and management of the claims clinical edit tool.
Initial work may include review of clinical edits, analyzing the current vs future state edits and other required analysis.
Conduct quality reviews of system adjudicated claims for errors in handling and pricing
Based on clinical coding expertise, assist with development, implementation and review of Fraud, Waste and Abuse tools to assure accurate claims processing.
Develop internal training, knowledge share content for peer-to-peer mentoring/knowledge share
Participate during project planning, assessment/workflow process, direct build progress of teams (or own team), development of testing plans, Parallel processes (user acceptance testing) and go live activities.
Participates in client communication process to develop and enhance client understanding of the project Best Practice, project timelines, tasks, client commitment, risk/issue impacts and mitigation.
Completes project tasks and assignments independently with general supervision
Use professional knowledge and experience to advise on optimal workflows and system functions.
Navigate across venues to resolve issues, propose mitigation strategies, and escalate when appropriate to solution and engagement leadership
Analyzes reasonably complex issues and develops/implements solutions with general guidance.
Uses knowledge to facilitate client workflow and gap analysis, independently with general guidance to complete documentation utilizing department standards.
Provides weekly status reports
Associate's or Bachelor's degree in Health Administration, Business Administration, Public Health or a related field or an equivalent amount of education and experience.
3+ years of experience required
CPC, RHIA or RHIT certification. Other AAPC or AHIMA certifications will be considered.
CCS-H, CCS-P, CPC, CPC-P, RHIT, RHIA Certified, or similar certification
1+ years' experience Optum CES software
5+ years of senior level experience
1+ years' experience in HIM auditing, consulting or analysis experience preferred
3+ years' experience in medical coding, billing/auditing, medical policy writing and/or compliance
Experience with all aspects of CPT/HCPCS/ICD-10 medical coding
Healthcare claims adjudication workflow, benefits configuration, policy management, and financial processing knowledge and experience
Claims editing software administration experience
They should know billing guidelines; they don't have to be proficient but be able to research what they do not know.
They would need to find and understand Tricare/VA policy.
Preferred knowledge of and/or experience with... For full info follow application link.
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled