Payment Integrity Coding Coordinator - Remote AZ

Blue Cross Blue Shield of Arizona•Tampa, FL

18d•Remote

About The Position

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This remote work opportunity requires residency, and work to be performed, within the State of Arizona. PURPOSE OF THE JOB The Coding Coordinator is responsible for performing audit activities in the areas of data mining, contract compliance, itemized bill reviews and provider outreach/education for all claim types to validate correct claims coding and billing practices. This role includes the identification and correction of abusive and wasteful billing and coding practices by conducting pre and post-payment coding compliance audits, communicating recommended solutions, and facilitating corrections, recovery of overpayments and provide education to promote correct, accurate and consistent coding and billing practices among providers.

Requirements

2 years of experience of professional/physician, inpatient, diagnostic and procedural coding, claims administration, claims auditing or related experience required (All Levels)
High-School Diploma or GED in general field of study (All Levels)
Certified Professional Coder (, CPC), or Certified Inpatient Coder (CIC)
Intermediate skill in use of office equipment, including copiers, fax machines, scanners and telephones
Intermediate PC proficiency
Intermediate proficiency in spreadsheet and word processing software
Basic skill in mathematics
Knowledge of medical terminology, ICD-10 CM & PCS, CPT and DRG codes
Ability to read, analyze, and interpret technical procedures, medical reports, fee schedules and medical coverage guidelines
Broad understanding of health insurance terms and concepts
General knowledge of the healthcare industry
Knowledge of coding principles and code sets including UB92, CPT, HCPCS , ICD 10, ADA, and ASA
Knowledge of UB92 guidelines.
Knowledge of Medicare rules and regulations
Awareness of claims processes and claims processing systems
Meticulous attention to detail
Ability to deal with ambiguity and make recommendations with less than complete or conflicting information while maintaining appropriate time management
Ability to maintain confidentiality and privacy
Ability to communicate effectively, both orally and in writing, to peers and direct management
Ability to build and maintain productive working relationships with others
Skill in prioritizing tasks and working with multiple priorities, sometimes under limited time constraints
Ability to summarize coding information to a general audience
Proactive about requesting enough information to fully understand and meet the business need
Analytical knowledge necessary to generate reports based on available data and then make sound decisions based on reported data

Nice To Haves

4 years of experience of medical coding, claims administration, claims auditing or related experience required (All Levels)
2 years of relevant hospital inpatient coding experience including DRG assignment
Experience with coding of all claim types (All Levels)
Associate or bachelor’s Degree in any general field of study. (All Levels)
Certified Professional Coder ( CPC), Certified Inpatient Coder (CIC) (All Levels)
Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephones
Knowledge of BCBSAZ corporate structure, functions, and procedures
Advanced proficiency in spreadsheet and word processing software
In-Depth knowledge of BCBSAZ products, processing systems, files, and computer software
Knowledge of fee schedules and medical coverage guidelines
Ability to communicate effectively, both orally and in writing, to all levels in all departments
Project management skill needed to create timelines, track deliverables and progress, resolve issues, and communicate project status

Responsibilities

Through data analysis, identify areas of high risk for coding and billing variances.
Collaborate with analyst to define reporting criteria to evaluate shifts in utilization and provider coding patterns.
Interprets data, draws conclusions, and reviews findings with all levels within the organization
Conducts audits of claims by selecting claims that have been identified as in scope for audit.
Audits claims, medical records and corresponding documentation for appropriate coding.
Applies knowledge of medical coding, diagnostic-related group (DRG) and current coding guidelines.
Performs hospital charge audits and itemized bill audits on all high dollar claims and as needed on other questionable charges applicable to outpatient/professional services.
Makes complex coding determinations and uses concise reasoning citing the principles and rational used in making the determination.
Prepares results/recommendations of the coding audit findings to the providers via claims adjustment notification letters and / or other direct communication.
Articulates clear and concise recommendations that may be challenged by health care providers.
Facilitates recovery efforts of claims that were identified as incorrectly billed.
Participate on task teams and corporate committees as required, applying coding and analytical skills
Quantifies the financial impact for the company and reports findings to management.
Acts as resource person for internal and external customers regarding coding and billing practices.
Develop, maintain and follow detailed procedures on the process and business rules around audits.
Manages ongoing audits and meets timeliness expectations.
Develops and maintains collaborative internal relationships.
Attend pertinent coding seminars and training, and use other resources as applicable, to maintain current knowledge of rapidly changing coding guidelines.
Proactively review and identify potential areas of high risk for coding and billing variances.
Develop and maintain a thorough understanding of medical coverage and reimbursement guidelines and make independent decisions.
Facilitates meetings to discuss areas of difficulty and variance by researching recognized national coding guidelines and medical data to encourage uniformity and consistency of coding practices among providers.
Participate on task teams and corporate committees as required, applying coding and analytical skills
Develop clear and concise recommendations for any potential coding or reimbursement changes including full rationalization and how it might interact with current processes and policies.
Present recommendations to the appropriate audience for review and approval.
Work closely with other areas of the company to ensure implementation and updates to methodologies are made timely and accurately.
Share knowledge of skills, projects, and business needs with peers and less experienced analysts.
Trains new employees as needed
Plan and lead multiple projects and cross-functional teams from inception to completion.
This includes working independently on creating timelines, working with other areas to define deliverables, monitoring progress, implementing the project and resolving/monitoring pre/post-implementation issues.
Lead and/or participate on task teams and corporate committees as required, applying analytical skills and actively participating in a team environment to complete projects and accomplish goals.
Demonstrate a strong business perspective, industry-knowledge, organizational skills and communication skills.
Work with and present to all levels of management, including Executives.
Independently manage and improve organizational processes.
Evaluate and create new ways to do things while making sure to incorporate input from all key stakeholders.
Keeps abreast of trends or technology that could improve work flow.
Demonstrate complete ownership and accountability in all leadership roles, process improvements and recommendations.
Identify and explore opportunities for medical and reimbursement policy changes that support claim savings goals, while maintaining focus on appropriate reimbursement levels and relativities.
Perform independent research to identify coding and system issues that impact medical coverage guidelines and pricing, presenting recommendations for appropriate corrective measures to management following thorough analysis & independent decision, while actively participating in the resolution.
Act as a liaison with health services, other divisions, external vendors and analysts to assure adequate communication and coordination of audit activities, medical and reimbursement policy and coding changes.
Support and train other employees in lower levels.
Help direct a thorough and efficient review of all audit work being produced in the area.
Reports to a supervisor or manager who provides minimal supervision/project management.
Develop own work-plans, and discusses timelines, prioritization, and objectives with supervisor or manager.
Each progressive level includes the ability to perform the essential functions of any lower levels and mentor employees in those levels.
Perform all other duties as assigned.