Medical Policy Implementation Specialist, Geisinger Health Plan (Eastern Standard Time Zone resident)

Geisinger • Work from home (Pennsylvania), PA

20h • Remote

About The Position

The Medical Policy Implementation Specialist supports the Medical Policy/Clinical Guidelines development area by investigating and auditing medical claims, analyzing data to guide policy development or revision, and making recommendations to management. The role evaluates claim coverage based on applicable medical policies, coding guidelines, and industry information, and serves as a resource to staff on policy implementation, coding, medical claims payment, claim edits, and benefit setup.

The specialist supports correct benefit configuration across lines of business, maintains code-configuration repositories and related databases, researches claim and clinical documentation, and coordinates implementation of coding updates and medical policy changes. The position also identifies operational deficiencies and process improvements related to claims payment, coverage, benefits, and financial liability. Work is performed from home in Pennsylvania and is typically conducted in an office environment. The role is scheduled for 40 hours per week on a day shift and requires residence in the Eastern Standard Time Zone.

Requirements

• High school diploma or equivalent (GED).
• At least 2 years of relevant experience; relevant work experience and education may be combined, with an associate degree counting as 2 years and a bachelor's degree counting as 4 years.
• Communication skills.
• Knowledge of health care policy and ethics compliance.
• Leadership skills.
• Residence in the Eastern Standard Time Zone.

Nice To Haves

• Experience with CPT coding.
• Experience with medical claims.
• Experience with benefit configuration.

Responsibilities

• Provide direction to benefits systems analysts to help ensure correct benefit configuration by line of business, and maintain repositories for code configuration changes resulting from medical policy development and government directives.
• Research and retrospectively review medical claims to assess compliance with contractual, state, and federal regulations.
• Request and review medical records to validate services billed to the medical benefit using unlisted or miscellaneous codes.
• Research reimbursement, medical record documentation, utilization, and proper coding.
• Review clinical documentation to determine coverage eligibility.
• Recommend system setup changes for proper claims adjudication and benefit coverage.
• Develop and maintain databases cataloging code status related to medical policy and state or federal mandates.
• Maintain coding matrices and databases related to contracted vendors, prior authorization requirements, Preventive Services, non-covered services, and Experimental and Investigational or Unproven services.
• Present information to committees about benefit configuration and claims in support of medical policy development initiatives.
• Produce ad hoc reports to assess utilization trends before and after implementation.
• Identify operational deficiencies and process improvements that could reduce the company's exposure related to medical claims payment, benefits, coverage, and financial liability.
• Investigate and audit medical claims, analyze data, and support policy development, revision, and reporting capabilities.
• Review and coordinate multi-departmental implementation of annual new codes and quarterly updates, and assign new coding to treatment types to ensure appropriate cost-sharing tiers.
• Continually audit claims and ensure compliance with current coding guidelines, industry information, and Health Plan policies.
• Address claims payment errors identified through audits and retrospective reviews.
• Process claims in the Facets workflow that pend for manual review by a medical policy implementation specialist.
• Review claim research request forms (CRRFs) to determine claim adjustment decisions.
• Provide CPT/HCPCS code guidance to GHP workgroups as needed.
• Participate in standing GHP operational meetings as needed.
• Comply with job-specific obligations and organizational policies and procedures.

Benefits

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

What This Job Offers

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