Medical Coding Appeals Analyst

Elevance Health•Richmond, IN

22h•Hybrid

About The Position

This role ensures accurate adjudication of claims by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. The position offers a virtual full-time work arrangement, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. Elevance Health is a Fortune 25 health company dedicated to improving lives and communities and making healthcare simpler. They are seeking leaders at all levels passionate about making an impact on members and communities. Elevance Health fosters a culture designed to advance its strategy and lead to personal and professional growth for its associates, rooted in values and behaviors that drive shared success. The company operates with a Hybrid Workforce Strategy, generally requiring associates to work at an Elevance Health location at least once per week, unless specified as primarily virtual by the hiring manager. Specific requirements for time onsite will be discussed during the hiring process. The health of associates and communities is a top priority, and new candidates in certain patient/member-facing roles are required to be vaccinated against COVID-19 and Influenza, with offers rescinded if not vaccinated, unless an acceptable explanation is provided or as required by law. Elevance Health is an Equal Employment Opportunity employer.

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.