Reports To: Director, Claims
Purpose: To provide clinical and technical analysis for interpretation of appropriate procedural and diagnostic coding and payment of claims and related inputs, i.e. authorizations, system configuration. Recommend and coordinate processes to enhance and problem solve new or inconsistent claim payment and coding policies. To develop and document claims coding adjudication policies. Operations lead to engage vendors or business partners that support claims processing for accurate payment policies. Maintain business decision support systems impacted by coding and payment policies with Health Services and Medical Operations.
1. Primary clinical and reimbursement coordinator with vendors and internal medical policy team to perform continuous claims reimbursement auditing.
2. Identifies and sponsors solutions of inconsistencies between CCI reimbursement policies and claim payment through review of suspended and appealed claims and audits of related AMISYS inputs which directly impact on claim payment (i.e. authorizations). Makes recommendations to resolve inconsistencies.
3. Technical Owner and Operations business content expert for procedure code not limited to unbundling software (GMIS’s ClaimCheck product) which includes customization of edits, coordination of testing of new releases with Information Services, and contact with the GMIS service representative for edit clarifications.
4. Operations Business Content Expert for clinical aspects and effectiveness of ClaimCheck to ensure consistent and appropriate procedure code reimbursement, to maximize savings from claims incorrectly coded by providers.
5. Operations Business Content Expert for system versions of claims reimbursement and policy systems for testing and upgrades.
6. Provide business requirements to the Configuration unit related to appropriateness of benefit setup and classifications of procedure codes as they relate to benefits to ensure accurate claim payments are made.
7. Provides education to employees and provider offices as needed to facilitate an understanding of correct claim coding, use of CPT4, ICD9, HCPCS, etc.
8. Provides education to employees of Medical Terminology as needed.
9. Collaborates with other areas and senior managers to provide clinical policy representation at meetings, to ensure that decisions, which affect inputs to claim payments are appropriate and will result in cost effective, efficient and accurate, claim reimbursement.
10. Operations Business Expert to process provider complaints and appeals including maintaining trends, Access database, evaluating effectiveness of processes, and recommending changes for continuous improvement.
11. Write letters and other correspondence and communicates with vendors and providers as needed. Accountable for timely turnarounds of complaints/appeal resolution.
12. Tracks reporting statistics and summarized data and compiles quarterly and year-end reports.
13. Monitor vendors that execute agreements to control claims expense through negotiation and audits, i.e. NurseAudit.
14. Performs review of all suspended and appealed claims requiring interpretation of clinical and pricing documentation (including but not limited to operative reports, office notes, system data) as it relates to the claim data, policies and standard CPT guidelines to provide consistent and fair reimbursement to providers.
15. Responsible for documenting claims adjudication policy.
16. Investigates provider aberrant/fraudulent billing practices utilizing paid claim data and review of medical records.
17. Performs other related projects and duties as assigned.
TECHNICAL KNOWLEDGE, EXPERIENCE AND SKILL REQUIREMENTS:
1. RN, LPN or Associates Degree in Nursing required, BSN preferable.
2. At least 2 years of health insurance industry coding standards experience; CPT, HCPCS and IDC9 coding certification required.
3. At least 2 years of Nursing experience in a medical/surgical acute care setting required.
4. At least 2 years experience in a managed care environment preferred.
5. At least 2 years experience with management of claim editing software required.
6. Ability to perform project management.
7. Prior experience in review of medical records preferred.
8. Proficient in the use of personal computers using Windows products.
9. Strong organizational, analytical, statistical and problem solving skills required.
10. Good oral and written communication skills required.
11. Strong business skills to interpret and monitor contract relationships.
1. Member and Customer Focus: Recognizes that members and customers (internal & external) are the driving force behind every business activity. Continuously makes an effort to exceed the expectations of members and customers.
2. Quality Orientation: Assumes responsibility for providing the highest level of quality to members and customers.
3. Innovation: The ability to see opportunities for change, to capitalize on them and implement them when appropriate for the benefit of ConnectiCare.
4. Communication: The ability to communicate with clarity both orally and in writing.
5. Teamwork: Demonstrates enthusiasm for the mission of ConnectiCare and inspires the same in others.
6. Results Orientation: The ability to break a complex problem down into its component parts and arrive at the appropriate solution in a timely fashion.
7. Change Mastery: Embraces change.
8. Learning Orientation: Assumes responsibility for personal and professional development.
ConnectiCare is an equal opportunity employer. M/F/D/V
ConnectiCare - 16 months ago
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