Medical Coding Analyst I
Excellus BlueCross BlueShield - Buffalo, NY

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Under the direction of the Supervisor of the Recovery Department, the Medical Coding Analyst l assures the appropriate payment of claims through the identification and retrospective audit of claims and/or medical records. Facilitates the daily work of the coding validation unit including DRG validation and readmission reviews for all lines of business in compliance with applicable law and regulation. Participates in the validation and adjustment of hospital coding. Audits cost and day outliers for payment determination and refers as appropriate to Utilization Management for review. Monitors cost savings targets and work plans to maintain cost containment initiatives. May work on special projects as assigned, in addition to daily work responsibilities.

Additionally, the Medical Coding Analyst ll, executes all of the Medical Coding Analyst l functions, while coordinating the daily work of the coding validation unit including DRG validation and readmission reviews for all lines of business in compliance with applicable law. Audits hospitals reimbursed on a percent of charge basis to determine how much the plan would have paid were the hospital reimbursed on a case payment. Conducts charge audits for assigned claims in coordination with Provider Reimbursement. Coordinates the analysis of data trends and recommends action plans to management. Handles department projects in addition to day-to-day activities and participates in committees and work groups relevant to departmental processes. Coordinates training sessions for department staff as a result of information learned at seminars and review of professional literature. Reviews, develops, and documents departmental policies and procedures.

Essential Responsibilities/Accountabilities
Medical Coding Analyst I
• Serves as liaison between the Plan and designated representatives of the hospitals in aspects of hospital reimbursement validation to ensure contract specifications are met. This can include but is not limited to data element verification. ICD-9-CM coding validation, monitoring plan specifications, DRG assignment accuracy, readmission review, and percent of charge verification.
• Travels to the provider’s place of business or requests the providers submit medical records to the Plan for review. Determines whether the medical record documentation supports the coding billed. Reports findings of the audit to the provider affording the provider the opportunity to appeal prior to adjusting the claim. Prepares and submits adjustments to the appropriate processing/adjustment area.
• Coordinates the collection and preparation of samples of hospital utilization data with the scheduling of hospital site visits ensuring completion of the audit within the regulated time frames. Performs pre-payment and post-payment cost and day outlier audits to determine appropriate claim payment levels.
• Interfaces with the Dispute Resolution Administrator (DRA) as necessary in response to provider appeals of DRG adjustments submitting the necessary documentation to support the corporate position. Maintains effective work relationships with Hospital Medical Records Departments and Business Office.
• Creates audit tools to facilitate the accurate and timely completion of the audit. Prepares and submits monthly cost savings reports and maintains relevant statistics on the program. Maintains accuracy in all coding and reimbursement methods researching the literature and attending professional seminars, workshops, and conferences as required by AHIMA to maintain professional certification.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
Medical Coding Analyst II
Performs similar functions as the Medical Coding Analyst I and can be differentiated by the following:
• Monitors audit targets and work plans to maintain cost containment initiatives. Coordinates the analysis of data trends and recommends programmatic changes to management. Prepares and submits monthly cost savings reports maintaining relevant programmatic statistics to guide the future development of the program.
• Collaborates with other operating teams in the development, implementation, evaluation and update of policies and procedures governing the adjustment of hospital claims, including communications to providers, and the servicing of provider inquiries.
• Interacts with management staff in functional areas within the department as requested to meet the operating team goals and objectives. Facilitates ongoing training for optimal staff functioning. Recommends, establishes and maintains criteria for review process and policy and procedure development. Maintains currency in all coding and reimbursement methods researching the literature and attending professional seminars, workshops and conferences as required by the AHIMA to maintain professional certification.
• Functions as a liaison between the Plan and designated representatives of the Hospital in aspects of hospital reimbursement validation to ensure contract specification are met. This can include but may not be limited to data element verification, ICD9-CM coding, DRG assignment accuracy, readmission review and percent of charge verification. Analyzes DRG patterns by hospital and conducts charge audits for assigned claims in coordination with Provider Reimbursement. For hospitals paid on a percent of charge basis, determine the DRG that would have paid, compare the actual payment to the DRG case payment, and incorporates this information into a monthly report to management.
Medical Coding Analyst I
• RHIT, RHIA or CCS Required
• Minimum of two years experience, preferably in a DRG Inpatient Coding setting
• Knowledge of Federal and State regulations and accreditation standards
• Knowledge of Medical Terminology, disease process and treatment methodologies
• Knowledge of provider reimbursement and all coding methodologies
• Knowledge of Provider contracts
• Knowledge of authorization and claims processing systems
• Strong analytical, problem solving skills
• Working knowledge of PC and mainframe software applications
• Knowledge of benefit and contract management
• Effective interpersonal skills/communication skills
Medical Coding Analyst II
• All Medical Coding Analyst l qualifications, plus
• Minimum of two years in Medical Audit
• Expertise in provider reimbursement and all coding methodologies
• Strong knowledge of authorization and claims processing systems
• Strong analytical, problem solving, and judgement skills
• Strong knowledge of PC and mainframe software applications
• Represents the Recovery Department in Corporate Committees
• Initiates education within the Plan or with a provider. Goals and outcomes of the education must be measurable.
• Ability to trend provider specific data and analyze for accurate reporting
• Ability to lead staff and projects in positive manner
• Demonstrates initiative for all facets of position responsibility
Physical Requirements
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer

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