Senior Coding Research Analyst

Magellan Health

8d • $58,440 - $93,500

About The Position

Manages claims coding rule process. Evaluates claims coding rule change request from clinical, financial, and claims operations perspectives. Provides regulatory and correct coding research on change requests and makes recommendations on correct payment policy and edit functionality. Defines requirements and partners with vendors throughout testing and implementation. Supports provider dispute/appeal team. Manages research of claims coding rule initiatives including the development of detail work plans. Receives and logs requests of changes for tracking purposes. Maintains a library of all the existing and retired rules, the source of the rule and the implementation/retire date of the rule (by Group/Plan/Division). Documents supporting authority for each claim coding rules by Group/Plan/Division (Master Grid). Participates in cross-functional teams to address key claims coding rule issues facing the organization. Administers communication to Network and collects feedback. Evaluates change proposal from a regulatory perspective, financial perspective, and claims operational perspectives. Seeks professional feedback from Health Services, Finance, and Claims on claims coding rule changes. Identifies coding error (e.g., upcoding, bundling/unbundling) and recommends correct coding of behavioral health claims. Research state laws and CPT/AMA guidance. Presents change proposals. Communicates effectively to network. Develops relationship with claims coding rule software vendors. Receives, researches, and determines appropriate action steps for escalated provider disputes from Dispute/Appeal team, Claims, and Network. Support Claims, Configuration, and/or Dispute/Appeal teams as necessary. Manages high visibility projects and provides recommendations and status to Leadership. Acts as the first point of contact in dealing with day to day business issues and support for problem resolution. Researches, analyzes, and presents savings opportunities to Leadership Perform other duties as assigned. The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description.

Requirements

• 5+ years of experience in the medical coding field with a facility, provider, or payer organization.
• Knowledge of CMS/State laws and AMA guidance.
• Advanced user and knowledge of claims payment system.
• Knowledge of 3M Encoder
• Strong knowledge of electronic medical records/billing systems and medical terminology and abbreviations.
• Billing expertise in UB92, 1500 and other healthcare services.
• Knowledge of one or more of the following: SQL, Xcelys, CES, iHT
• Demonstrated written communication skills.
• Demonstrated leadership skills.
• Demonstrated interpersonal/verbal communication skills.
• Ability to work as part of a team.
• Demonstrated problem solving skills.
• CCS - Certified Coding Specialist - Enterprise

Nice To Haves

• Associate degree preferred, but a combination of education and experience will be considered.
• Associate
• Enterprise

Responsibilities

• Manages claims coding rule process.
• Evaluates claims coding rule change requests from clinical, financial, and claims operations perspectives.
• Provides regulatory and correct coding research on change requests and makes recommendations on correct payment policy and edit functionality.
• Defines requirements and partners with vendors throughout testing and implementation.
• Supports provider dispute/appeal team.
• Manages research of claims coding rule initiatives including the development of detail work plans.
• Receives and logs requests of changes for tracking purposes.
• Maintains a library of all the existing and retired rules, the source of the rule and the implementation/retire date of the rule (by Group/Plan/Division).
• Documents supporting authority for each claim coding rules by Group/Plan/Division (Master Grid).
• Participates in cross-functional teams to address key claims coding rule issues facing the organization.
• Administers communication to Network and collects feedback.
• Evaluates change proposal from a regulatory perspective, financial perspective, and claims operational perspectives.
• Seeks professional feedback from Health Services, Finance, and Claims on claims coding rule changes.
• Identifies coding error (e.g., upcoding, bundling/unbundling) and recommends correct coding of behavioral health claims.
• Research state laws and CPT/AMA guidance.
• Presents change proposals.
• Communicates effectively to network.
• Develops relationship with claims coding rule software vendors.
• Receives, researches, and determines appropriate action steps for escalated provider disputes from Dispute/Appeal team, Claims, and Network.
• Support Claims, Configuration, and/or Dispute/Appeal teams as necessary.
• Manages high visibility projects and provides recommendations and status to Leadership.
• Acts as the first point of contact in dealing with day to day business issues and support for problem resolution.
• Researches, analyzes, and presents savings opportunities to Leadership.
• Perform other duties as assigned.

Benefits

• This position may be eligible for short-term incentives as well as a comprehensive benefits package.
• Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree