Medicaid Modernization Certified Clinical Coder - Program Specialist V (PS V)

TX-HHSC-DSHS-DFPS • Austin, TX

13d

About The Position

The Medicaid Modernization Certified Clinical Coder PS V reports to one of the Medical and Dental Benefits Policy (MDBP) Managers in the Medicaid Office of Policy. This position is expected to have experience and strong working knowledge of CPT, HCPCS, NCCI, ICD, revenue codes, modifiers, groupings, system crosswalks, claims system functions, current medical billing and coding practices, and knowledge of taxonomies and provider types. This position requires a current certificate and will actively participate in Medicaid modernization activities related to claims systems and medical billing and coding functions, to include national to local place of service coding crosswalks, coding setup, and coding quality assurance, while assisting in technology change decisions.

The Medicaid Modernization Certified Clinical Coder PS V performs advanced consultative and technical work related to the development and implementation of Texas Medicaid medical benefits as well as system modernization efforts. Medicaid modernization is an agency-wide project to streamline and update the highly complex network of interconnected systems that support Texas Medicaid delivery. This PS V’s work focuses on medical billing and coding, claims system standards, and researching related questions to provide concise analysis, recommendations, and well-written responses. This position will serve as one of the MDBP liaisons for Medicaid modernization, collaborating within MDBP and between Program Policy, MCS Operations, HHSC Information Technology, and technology and claims system vendors, among others. This role will serve as a billing and coding analyst on MDBP policy questions and projects related to Medicaid benefits, billing processes, as well as the related technology and system changes that best supports Medicaid’s medical and dental benefit policies.

This position analyzes and researches medical billing and coding impacts to Medicaid’s medical benefits, identifies needs for coding changes and makes related policy recommendations. The Medicaid Modernization Certified Clinical Coder PS V must be able to provide clear, concise, plain language explanations of complex and technical information. The PS V researches state and federal regulations as well as coding best practices to apply findings to their work.

This position requires excellent writing skills, strong research skills, excellent presentation and communication skills, the ability to provide recommendations in plain but professional language while also providing evidence of reasoning. This position works under the general direction of an MDBP Manager with a high degree of latitude for the use of initiative and independent judgment.

Requirements

• A Medical Billing and Coding Certificate is required.
• Certificate is preferred through the American Health Information Management Association AHIMA (CCS-P, CCS) or American Association of Professional Coders AAPC (COC, CPC, CIC) or Practice Management Institute PMI (CMC).
• Note: Proof of current medical billing and coding certification must be listed on the application to be considered for this position. Incomplete applications will not be considered.
• Knowledge of: Health and Human Services agencies and programs, HCPCS, CPT, NCCI and ICD coding information, CMS and CMS medical coding and billing structures, Federal and state medical billing and coding compliance, State and Federal Medicaid Plan statutes and regulations, Provider type taxonomies for provider enrollment standards
• Skill in: Analyzing and evaluating complex federal and state legislation, Researching, analyzing, and synthesizing medical policy language, claim processing systems information, and related program issues, Developing and evaluating policies and procedures to assess risks and make billing and coding policy recommendations, Written and oral communication, including making public presentations, and writing technical information into understandable plain-language formats, Project planning, evaluation, and implementation, Use of Microsoft Office products and applications (Word, Excel, PowerPoint, Teams, SharePoint, etc.)
• Ability to: Effectively communicate, facilitate meetings, and maintain working relationships with staff and program stakeholders, Exercise critical thinking and creative problem-solving techniques in a highly complex environment, Participate and provide recommendations in technology systems-oriented workgroups, Work cooperatively as a team member in a fast-paced, deadline-orientated environment, Work independently and perform work with a high degree of attention to detail, Manage several projects concurrently and juggle competing priorities, Be flexible, to pivot from a known present-state to an unknown future-state requiring adaptability, risk management, and planning skills for evolving possibilities
• Required: Medical billing and coding experience or expertise is required.
• Required: At least 2 years of coding-related work experience (e.g., inpatient, outpatient, hospital or clinic setting, or with health insurance or healthcare plans, etc.).

Nice To Haves

• Preferred: Graduation from an accredited college or university with major course work in healthcare administration, public health, public policy, or a related field.
• Preferred: Experience with publicly funded health care programs, such as Medicaid.
• Preferred: Experience with updating and modernizing technology systems.
• Note: Work experience and education may be substituted for one another at the discretion of the hiring manager.

Responsibilities

• Researches, analyzes, and synthesizes Medicaid medical benefit policy, complicated federal and state regulations, client information, and claims processing information for medical benefit reviews with a focus on medical coding and billing related projects.
• Analyzes, researches, and tracks quarterly and annual ICD, CPT, HCPCS, and NCCI changes.
• Conducts research on managed care organization (MCO) benefit coverage, private payer benefit coverage, CMS coverage, and other state Medicaid benefit coverage and related coding and provider enrollment setups during the policy development process.
• Keeps team apprised of billing and coding updates and related information.
• Participates in special modernization projects and activities related to claims system coding, national and local coding crosswalks, taxonomies and provider types, and policy language quality assurance.
• Participates and may lead in the development, planning, and implementation of new or revising current medical benefit policies and technology systems functions for Medicaid and Medicaid modernization and provider enrollment management systems.
• Researches, analyzes, and synthesizes very technical information such as claim systems information, coding standards, provider taxonomies, evidence-based practices, and peer-reviewed literature using a variety of resources and websites.
• This position applies findings and explains billing and coding impacts to medical and dental benefit policies.
• Collaborates with MDBP staff, as well as HHSC staff in other programs and other State agencies, and the claims system administrators for program benefit policy development, planning, implementation, and modernization activities.
• Participates in meetings and discussions by providing summaries, explanations, comments, and recommendations orally or in writing.
• Performs quality review of policy language and claims processing system setups to ensure all changes are appropriate and have been captured accurately.
• Provides training, technical assistance, and guidance to staff on clinical coding and billing and provider enrollment configurations.
• Responds in timely manner to internal/external communications and requests for related coding and policy information.
• Prepares policy updates, summaries, reports, or other documents and keeps management informed of pertinent issues in a timely and professional fashion.
• Works with internal and external stakeholders to identify the need for coding and policy changes through the analysis of claims appeals and denials, provider complaints, billing and coding issues, claims system issues, provider enrollment requirements, and prior authorization requests.
• Participates and may lead meetings or workgroups engaged in research and evaluation of medical benefit issues or modernization efforts.
• Acts as the liaison with HHSC staff and other business areas and agencies by providing complex technical assistance and guidance on claims system modernization and coding and billing related changes.
• Collaborates with HHSC staff and other HHS agencies to ensure that medical benefits information in the Texas Medicaid Provider Procedures Manual (TMPPM) and other Medicaid materials are accurate and in accordance with policies and procedures.
• Participates in post-implementation utilization and review meetings for medical and dental policies to identify if additional benefit changes are necessary and provides guidance and advice on how to implement these changes.
• Assists in developing complex memos, briefs, and other documents for HHSC leadership regarding medical benefit changes.
• Develops and provides recommendations for benefit coverage to HHSC leadership.
• Also provides regular updates on modernization activities.
• Supports team members in the development of medical benefit policy and assists with medical billing and coding questions as well as provider enrollment configuration questions.
• Other duties, as assigned, include but not limited to actively participating in or serving in a supporting role to meet the agency’s needs.

Benefits

• Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed