Provides expertise in the areas of coding, insurance reimbursement, compliance initiatives, regulatory legislation and billing practices. Provides customer service to other departments regarding coding and medical review issues and review any claim or appeal that is brought to the Medical Review Department.
1. Reviews medical claims and monitors billing practices to ensure accurate coding. Reviews billed services for compliance with accepted industry standards. Reviews claims with multiple surgical interventions, unlisted procedures and unusual services to determine appropriate levels of reimbursement. Reviews modifiers for appropriateness of payment. Performs retrospective reviews. Keeps review decisions with ERISA standards. Tracks workflow to monitor and improve the medical review process.
2. Works with coding department to initiate, develop and implement adjudication policy as it relates to codes received on billing sources. Develops and documents workflow processes.
3. Works with other departments to understand impact of coding processes on other areas. Analyzes and recommends updates and changes to clinical editing software. Acts as a resource for coding issues and configuration. Maintains clinical editing customization as it relates to claims payment.
- Bachelor's degree in a health or business related field from an accredited institution which will be verified; or four years work experience in a healthcare related field, of which three years needs to be in the health insurance industry.
- One year of specialty claims processing experience.
- One year customer service experience.
- Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician-based (CCS-P) certification through AHIMA, or Certified Professional Coder (CPC), Certified Professional Coder-Hospital (CPC-H), or Certified Professional Coder-Payer (CPC-P) through AAPC, or Physician Coding Specialist (PCS), Facility Coding Specialist (FCS) or Coding Specialist for Payers (CSP) through ACMCS.
- Demonstrated intermediate knowledge of CPT-4, ICD-9-CM, ICD-10, HCPCS, DRG's and revenue codes gained either through complex specialty claims processing or equivalent formal coding training.
- Demonstrated intermediate level experience spreadsheet and word processing applications.
- Manual dexterity, hearing, seeing, speaking.
- Experience with editing software.
- Broad knowledge of insurance plans.
- Broad knowledge of Relative Value Units, billing procedures, human anatomy and physiology, insurance regulations and compliance.
- Excellent organizational, analytical and communication skills.
- Demonstrated ability to establish and maintain rapport with co-workers, physicians and other health care providers.
- Demonstrated ability to perform tasks independently and with minimal supervision.
- Demonstrated sound judgment and decision making skills.
All positions subject to close without notice
Intermountain Healthcare is an equal opportunity employer M/F/D/V
Intermountain Healthcare is an internationally recognized system of 22 hospitals and a full range of medical services, multi-specialty...