Coding and Cost Analyst I, Geisinger Health Plan (Eastern Standard Time Zone resident)

Geisinger•Work from home (Pennsylvania), PA

6d•Remote

About The Position

The Coding and Cost Analyst I contributes to Geisinger Health Plan’s strategic and financial goals by reviewing billed services, authorizations, plan benefit documents, itemized statements, medical records, discharge summaries, and detailed data reports. The analyst makes reimbursement or recovery recommendations based on coding, billed statistics, policies, industry standards, and compliance with contractual, state, and federal regulations. The role supports other Health Plan departments with coding, billing, and reimbursement reviews; conducts clinical reviews related to claims, claim edits, appeals, and grievances; and assists with analysis of clinical risk for Underwriting, Pharmacy, and Finance. The analyst reviews and validates pended and reconsidered claims, including claims processed through editing software from multiple vendors, and reviews high-dollar inpatient and outpatient claims and quality concerns. The position also validates claim payments against Plan contracts, maintains reports, participates in discussions and workgroups, and may assist with onboarding new team members. Work is typically performed from a secure home office in Pennsylvania that complies with HIPAA privacy standards. Occasional onsite department meetings may be required. The position requires a CPC certification through AAPC or CCS certification through AHIMA. An LPN is preferred. A high school diploma or GED is required, and a specialty training program is preferred. At least three years of relevant experience is required; two years of clinical experience is preferred.

Requirements

High school diploma or equivalent GED.
Minimum of 3 years of relevant experience; related work experience and completed specialty training may be combined, with 1 year of specialty training counting as 1 year of relevant experience.
CPC—Certified Professional Coder through AAPC, or CCS—Certified Coding Specialist through AHIMA.
Computer literacy, critical thinking, and organizing skills.
Ability to work from a secure home office that follows HIPAA privacy standards.

Nice To Haves

LPN.
Graduate of a specialty training program.
Minimum of 2 years of clinical experience.

Responsibilities

Support Health Plan departments by reviewing and recommending correct coding, appropriate billing, and reimbursement.
Complete clinical reviews related to claims, claim edits, appeals, and the grievance process.
Assist in analyzing clinical risk related to Underwriting, Pharmacy, and Finance departments.
Recommend recovery efforts based on current contracts, policies, procedures, and accepted industry standards.
Review and validate pended and reconsidered claims when edits are applied by claim-editing software from multiple vendors, using CPT, industry, and CMS guidelines.
Review high-dollar inpatient and outpatient claims according to internal guidelines and assist with reviews of quality concerns.
Validate claim payments based on Plan contracts, often working with the Pharmacy team and the PNM department.
Create and maintain reports to track department data.
Assist with group discussions about challenging medical reviews.
Assist with onboarding new team members as needed.
Participate in selected workgroups and committees on an ad hoc basis as requested.
Attend occasional onsite department meetings as needed.