Med Coding Appeals Analyst

Elevance Health • Tampa, FL

3d • Hybrid

About The Position

Ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. PRIMARY DUTIES: Review medical record documentation in support of Evaluation and Management, CPT, HCPCS and ICD-10 code. Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducting clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy. Translates medical policies into reimbursement rules. Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits. Coordinates research and responds to system inquiries and appeals. Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy. Perform pre-adjudication claims reviews to ensure proper coding was used. Prepares correspondence to providers regarding coding and fee schedule updates. Trains customer service staff on system issues. Works with providers contracting staff when new/modified reimbursement contracts are needed.

Requirements

• Requires a BA/BS degree and a minimum of 2 years related experience; or any combination of education and experience, which would provide an equivalent background.
• Certified Professional Coder (CPC) or Registered Health Information Administrator (RHIA) certification required.

Nice To Haves

• CEMC, RHIT, CCS, CCS-P certifications preferred.

Responsibilities

• Review medical record documentation in support of Evaluation and Management, CPT, HCPCS and ICD-10 code.
• Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducting clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.
• Translates medical policies into reimbursement rules.
• Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits.
• Coordinates research and responds to system inquiries and appeals.
• Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.
• Perform pre-adjudication claims reviews to ensure proper coding was used.
• Prepares correspondence to providers regarding coding and fee schedule updates.
• Trains customer service staff on system issues.
• Works with providers contracting staff when new/modified reimbursement contracts are needed.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees