Claim Edit and Vendor Integrity Specialist, Geisinger Health Plan ( Eastern Unit
工作地点：从家 （宾夕法尼亚州）班级：日期 （美国）计划周休：40个工作时间类型：定期豁免状态：是的就业总结：我们的成功候选人在医疗保健索赔或支付完整性环境中与外部供应商合作经验，包括实施支持，索赔编辑验证，问题升级和解决，绩效监测以及持续的供应商关系管理。工作职责：作为领导者，联络员和资源，与包括管理层，医生，临床和非临床人员在内的多个团体合作，利用国家正确编码标准，方法和行业标准编码规则来支持和扩大内部和外部战略。· 对 CPT,ICD-10和 HCPCS 编码技能的广泛知识用于维护和开发潜在的索赔修改和伙伴关系。·确定支付符合临床和退款政策。·根据需要研究 CPT 代码以澄清编码问题。· 确定与现有供应商合作伙伴关系和实施的机会，同时探索新的机会。· 对年度机会分析进行协调，审查并建议改变。· 评估并响应要求编辑呼吁和理性请求。· 协调，支持和解决供应商需求，无论是前景还是后期。· 解决系统/索赔编辑问题。· 测试和验证新要求编辑作为维护的一部分以及在新供应商的实现过程中。· 领导编辑扩展委员会作为一个组成部分。· 与供应商伙伴举行常规维护和监督会议。· 作为主题专家，支持内部工作组/委员会等。· 与提供商和/或账户管理人员进行互动以澄清发现的文档和结算问题。· 领导内部开发，测试，维护和扩大内部索赔编辑。· 负责 ClaimsXten 政策管理模块的发展。· 导师不具经验的人员和新聘者。· 编译并协调各种供应商倡议的常规绩效报告，并支持各种报告会议。通常在办公环境中开展的工作。负责满足所有特定职位义务以及遵守组织的所有政策和程序。本资料中的具体声明不应全部包含
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Location:
Work from home (Pennsylvania)Shift:
Days (United States of America)Scheduled Weekly Hours:
40Worker Type:
RegularExemption Status:
YesJob Summary:
Our successful candidate has experience collaborating with external vendors in a healthcare claims or payment integrity environment, including implementation support, claim-edit validation, issue escalation and resolution, performance monitoring, and ongoing vendor relationship management.Job Duties:
Acts as a leader, liaison, and resource working collaboratively with a diverse group, including management, physicians, clinical and non-clinical personnel utilizing the national correct coding standards, approaches, and industry standard coding rules to support and expand internal and external strategies.
- Applies expanded knowledge of CPT, ICD-10 and HCPCS coding skills toward the maintenance and development of prospective claim edits and partnerships.
- Determines payment compliance with clinical and reimbursement policies.
- Researches CPT codes to clarify coding issues, as required.
- Determines opportunities with current vendor partnerships and implementations, exploring new opportunities as well.
- Coordinates, reviews, and recommends changes for the yearly opportunity analysis.
- Reviews and responds to claim edit appeals and rational requests.
- Coordinates, supports, and resolves vendor needs both prospectively and retrospectively.
- Problem solves system/claim edit issues that may come up.
- Tests and verifies new claim edits as a component of maintenance and during implementation for new vendors
- Leads the Edit Expansion Committee as a component
- Leads routine maintenance and oversight meetings with vendor partners
- Acts as a subject matter expert in support of internal workgroups/committees, etc.
- Interacts with providers and/or Account Managers to clarify documentation and billing issues identified.
- Leads internal development, testing, maintenance, and expansion of internal claims edits.
- Leads the development of the ClaimsXten Policy Management Module.
- Mentors less experienced staff and new hires.
- Compiles and coordinates routine performance reporting for various vendor initiatives and supports various report out meetings.
Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Position Details:
Minimum of one Certification required:
Certified Professional Coder (CPC) with AAPC
Certified Coding Specialist with AHIMA certifications
Education:
High School Diploma or Equivalent (GED)- (Required), Graduate from Specialty Training Program- (Preferred)Experience:
Minimum of 5 years-Related work experience (Required), Minimum of 5 years-Health Insurance/Managed Care (Preferred)Certification(s) and License(s):
Certified Coding Specialist - American Health Information Management Association (AHIMA), Certified Professional Coder - American Academy of Professional Coders (AAPC)Skills:
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities.
- KINDNESS: We strive to treat everyone as we would hope to be treated ourselves.
- EXCELLENCE: We treasure colleagues who humbly strive for excellence.
- LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow.
- INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
- SAFETY: We provide a safe environment for our patients and members and the Geisinger family.
We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality.
Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.
Originally posted on Himalayas