Claim Edit and Vendor Integrity Specialist, Geisinger Health Plan ( Eastern United States resident )

Geisinger • Work from home (Pennsylvania), PA

21d • Remote

About The Position

The Claim Edit and Vendor Integrity Specialist works collaboratively with external vendors in a healthcare claims or payment integrity environment. The role supports vendor implementations, validates claim edits, escalates and resolves issues, monitors performance, and manages ongoing vendor relationships. It also applies national correct coding standards and industry coding rules to support internal and external strategies.

The specialist develops and maintains prospective and internal claims edits, evaluates payment compliance with clinical and reimbursement policies, researches coding issues, and identifies opportunities with existing and potential vendor partnerships. The role coordinates annual opportunity analysis, reviews and responds to claim edit appeals and rational requests, supports vendor needs prospectively and retrospectively, and troubleshoots system and claim-edit issues.

The position leads the Edit Expansion Committee, vendor oversight meetings, internal workgroups, and development of the ClaimsXten Policy Management Module. It tests and verifies claim edits, interacts with providers or Account Managers to clarify documentation and billing issues, mentors less experienced staff and new hires, and coordinates performance reporting for vendor initiatives. Work is typically performed in an office environment; the position is listed as work from home in Pennsylvania.

Requirements

• High school diploma or GED required.
• At least 5 years of related work experience required.
• At least one coding certification is required: Certified Professional Coder (CPC) through AAPC or Certified Coding Specialist through AHIMA.
• Experience working collaboratively with external vendors in a healthcare claims or payment integrity environment, including implementation support, claim-edit validation, issue escalation and resolution, performance monitoring, and vendor relationship management.
• Knowledge of CPT, ICD-10, and HCPCS coding.

Nice To Haves

• Graduate of a specialty training program preferred.
• At least 5 years of health insurance or managed care experience preferred.

Responsibilities

• Collaborate with management, physicians, clinical and non-clinical personnel using national correct coding standards and industry coding rules to support internal and external strategies.
• Apply CPT, ICD-10, and HCPCS coding knowledge to maintain and develop prospective claim edits and partnerships.
• Determine payment compliance with clinical and reimbursement policies.
• Research CPT codes to clarify coding issues as required.
• Identify opportunities with existing vendor partnerships and implementations and explore new opportunities.
• Coordinate, review, and recommend changes for the yearly opportunity analysis.
• Review and respond to claim edit appeals and rational requests.
• Coordinate, support, and resolve vendor needs prospectively and retrospectively.
• Troubleshoot system and claim-edit issues.
• Test and verify new claim edits during maintenance and vendor implementation.
• Lead the Edit Expansion Committee.
• Lead routine maintenance and oversight meetings with vendor partners.
• Serve as a subject matter expert supporting internal workgroups and committees.
• Interact with providers and/or Account Managers to clarify documentation and billing issues.
• Lead internal development, testing, maintenance, and expansion of internal claims edits.
• Lead development of the ClaimsXten Policy Management Module.
• Mentor less experienced staff and new hires.
• Compile and coordinate routine performance reporting for vendor initiatives and support report-out meetings.
• Satisfy job-specific obligations and comply with organization policies and procedures.

Benefits

• Healthcare benefits for full-time and part-time positions from day one, including vision, dental, and domestic partner benefits.
• Collaborative, cooperative, and collegial work atmosphere.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: High school or GED