Hybrid Claims Coding Analyst

at Healthfirst

• Job title: Claims Coding Analyst
• Job type: Full Time
• Experience level: Mid level, Senior
• Salary: $68,900 - $99,620 per year
• Degree requirement: High School Diploma
• Location requirements: Hybrid, New York City, United States

About the role

• Claims Coding Analyst handling claims editing and provider disputes at Healthfirst. Ensuring policy compliance with CMS and other coding guidelines while leading continuous improvement initiatives.

Responsibilities

• Conducts independent assessments of current claims edits to ensure comprehensive and defensible claims editing is in place across all Healthfirst product lines.
• Proactively identifies areas of opportunity with respect to new edits, modifications to existing edits, and recommended claims policy changes.
• Leads implementation efforts with respect to new or modified edits and works with other departments to ensure proper integration with existing systems and edits.
• Monitors and reports on performance of current claims editing packages to substantiate savings to Healthfirst.
• Serves as a subject matter expert to defend claims payment policy disputes and appeals.
• Reviews claims editing escalated provider disputes/appeals and provides guidance on coding rules and industry standards across all areas of the company with regards to claims editing and proper coding, billing, and payment.
• Researches and provides feedback on claims editing performance issues, both internally and externally with providers, vendors, etc.
• Collaborates with claims editing vendors to maintain and update edits as changes in the regulatory, legislative, or industry accepted payment policy requires.
• Collaborates with other departments to improve compliance with coding conventions and clinical practice guidelines.
• Leads continuous improvement and quality initiatives to improve processes across departments.
• Reviews and responds to written provider disputes, clearly and articulately outlining the payment discrepancy to the provider.
• Thoroughly researches post payment claims and takes appropriate action to resolve identified issues within turnaround time requirements and quality standards.
• Navigates CMS and State specific websites, as well as AMA guidelines, and compares to current payment policy configuration to resolve the provider payment discrepancies.
• Reviews medical records to ensure coding is consistent with the services billed and compares against the clinical coding guidelines to determine if a claim adjustment is necessary.
• Processes claim adjustment requests following all established adjustment and claim processing guidelines.
• Identifies and escalates root cause issues to supervisor for escalated review.
• Reviews and responds independently to internally escalated provider disputes transferred by management and other associates.

Requirements

• Coding certification from either American Academy of Professional Coders (AAPC), Certified Professional Coders (CPC) or American Health Information Management Association (AHIMA).
• High school diploma or GED from an accredited institution.
• Previous relevant experience
• Bachelor’s degree in related field
• Time management, critical/creative thinking, communication, and problem-solving skills
• Demonstrated professional writing, electronic documentation, and assessment skills.
• Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills.
• Knowledge of anatomy and pathophysiology medical terminologies.

Benefits

• medical, dental and vision coverage
• incentive and recognition programs
• life insurance
• 401k contributions