This position functions as a key component of the coding and reimbursement research area which provides support for contract development, system configuration, code maintenance, member benefits, medical policies, editing, correct coding education, provider disputes, appeals, customer service and claim adjudication as applicable to all lines of BCBST products.
Job Duties & Responsibilities
o Professional services (e.g. anesthesia, dental, surgery, radiology, clinical laboratory, pathology, non-clinical laboratory, evaluation and management, and diagnostic/therapeutic services)
- Research, design, analysis, recommendation, implementation, problem resolution, maintenance and coordination of coding and reimbursements for one of the following specialized areas:
o Facility services (e.g. inpatient/outpatient acute care, ambulatory surgery, inpatient/outpatient rehabilitation, dialysis clinic, skilled nursing facility, and hospice services)
o Home health services (e.g. home health agency, home obstetrical management, home infusion therapy, durable medical equipment, custom durable medical equipment, medical supplies, orthotics, prosthetics, hearing products, and vision products) including immune globulins, vaccines, toxoids, injectable drugs, radiopharmaceuticals, contrast materials, enteral nutrition, parenteral nutrition, and specialty nutritional foods
- Responsible for the evaluation, development, implementation and maintenance of:
- Coding policies and procedures in accordance with industry standard coding conventions to support provider billing, contracting, adjudication, and reporting efforts.
- Code editing (i.e. code bundling, global periods, gender age, diagnosis/gender, diagnosis procedure edits) rules including maintenance.
- Provides oversight for activities performed by department.
- Reviews and provides final approval for responses to provider appeals and legislative inquiries when delegated by the Research and Consulting Manager
- Independently reviews and resolves inquiries (i.e. claims, customer service, provider reconsiderations, provider appeals, and legislative inquiries) to determine appropriate coding and/or reimbursement based on established guidelines, policies, and procedures when all required supplemental information is provided (e.g. operative report; medical records; name of drug, National Drug Code, strength, and quantity; manufacturer name, product name, product number, quantity; manufacturer/supplier's invoice listing acquisition cost, etc.)
- Refers inquiries to the appropriate analyst or manager if established guidelines, policies, and procedures are not available
- Maintains proficient knowledge and ensures corporate compliance with HIPAA Administrative Simplification Medical/Clinical Code Sets (i.e. CDT-Current Dental Terminology, CPT-Current Procedural Terminology, HCPCS-Healthcare Common Procedure Coding System, and ICD-International Classification of Diseases)
- Develops educational material to be used in training for Coding and Reimbursement Research staff and other internal staff.
- Researches and prepares coding and reimbursement policies and procedures and billing guidelines to be included in the BCBST publications (e.g. BlueAlert, Commercial Provider Administration Manual, and BlueCare Provider Administration Manual)
- Interacts with all levels of staff in the organization regarding reimbursement and coding issues and initiatives
- Coordinates the implementation of coding, reimbursement, and billing changes with reimbursement development and contract support, contract configuration administration, systems configuration, I/S, operations, finance, health care services, medical policy, provider contract compliance, provider education, provider relations, provider audit, special investigations unit, etc.
- Serves in an advisory capacity regarding coding, reimbursement, and billing issues on various corporate committees, workgroups, and/or sub-workgroups
- Serves as a liaison between BCBST, BCBSA, BCBS plans, Centers for Medicare and Medicaid Services, Medicare Carriers/Fiscal Intermediaries, American Medical Association, American Dental Association, Tennessee Medical Association, Tennessee Hospital Association and providers regarding coding/billing issues
- Provides coding consultations to support BlueCross BlueShield of Tennessee administrative functions such as, but not limited to member benefits, case management, disease management, utilization management, clinical risk management, medical policy, provider contracting, provider reimbursement, provider relations, internal audit, provider audit, enterprise investigative services underwriting initiatives
- Reviews, prioritizes, prepares, and presents recommendations code editing changes
- Detects and reports potential provider coding education opportunities potential provider fraudulent/aberrant billing practices to Provider Audit and/or Enterprise Investigative Services.
- Other duties or responsibilities assigned by Management
- Overnight travel may be required to perform the aforementioned functions
- Bachelor's degree in nursing, health information management or related health care field or equivalent work experience is required.
- Active Tennessee nursing licensure is preferred.
- Four or more years experience with medical/clinical coding (i.e. CDT-Current Dental Terminology, CPT-Current Procedural Terminology, HCPCS-Healthcare Common Procedure Coding System, and ICD-International Classification of Diseases) is required. Coding certification from a nationally recognized coding organization (i.e. American Academy of Professional Coders-CPC or CPC-H certification, American Health Information Association CCS-P or CCS certification) is required.
- Proficient knowledge and understanding of BlueCross BlueShield of Tennessee and Medicare provider reimbursement methodologies for at least two of the following specialty areas is required: Professional services, Facility services or Home health services.
- Proficient knowledge and understanding of Health Insurance Portability and Accountability Act (HIPAA) standardized claims transaction and medical/clinical code sets is required.
- Previous project management experience including coordinating cross-functional activities is required. Previous management/supervisory experience is required.
- Proficient knowledge and understanding of Microsoft products is required.
- Proficient knowledge and understanding of Facets claims, customer service, member benefits, authorization, and provider reimbursement applications and configuration is essential.
- Proficient knowledge and understanding of the Burgess Reimbursement System is essential.
- Proven problem solving abilities, strong analytical skills, initiative, ability to work independently, and ability to coordinate department assignments and cross-functional/multi-divisional activities is required.
- Must be well organized and have experience in managing multiple assignments with critical deadlines.
- Excellent human relations and communications skills (both verbal and written) are essential.
BlueCross BlueShield of Tennessee (BCBST) is the oldest and largest not-for-profit managed care provider in the state of Tennessee....