Coding and Cost Analyst I, Geisinger Health Plan (Eastern Standard Time Zone resident)

Geisinger; United States; Remote; USD 55,000 - 85,000; Full time

Benefits offered by this job

Work-from-home option

HIPAA privacy compliance

Job summary

Geisinger is seeking a skilled Medical Coder to review and advise on coding, billing, and reimbursement across Claims, Edits, Appeals, and Grievances. The role supports inpatient and outpatient high-dollar claims and collaborates with Pharmacy and PNM teams.

The candidate will validate payments according to contracts, participate in workgroups, and assist with onboarding. A CPC/CCS certification is required, with LPN preferred, and remote work options are available.

Qualifications

• Proven CPT/CMS guideline knowledge is required.
• Experience reviewing Claims, Edits, Appeals, and Grievances is essential.
• Proficiency with HIPAA privacy practices is expected.

Responsibilities

• Provide review and recommendations for correct coding, billing, and reimbursement.
• Complete clinical reviews for Claims, Claim Edits, Appeals, and Grievance processes.
• Recommend recovery efforts based on contracts, policies, procedures and industry standards.
• Review and validate pended/reconsidered claims with plan editing software (vendors).
• Complete reviews on inpatient and outpatient high-dollar claims and assist with quality concerns.
• Validate claim payments in line with Plan contracts and collaborate with Pharmacy and PNM teams.
• Create and maintain various department reports.
• Assist in onboarding new team members and participate in ad hoc workgroups or committees.
• Attend occasional onsite department meetings as needed.

Skills

Medical coding review

Billing compliance

Claims analysis

Education

CPC-Certified Professional Coder (AAPC)

CCS-Certified Coding Specialist (AHIMA)

LPN preferred

Tools

Plan claim editing software

Job description

• Supports and serves as a resource to other Health Plan departments by providing review and recommendation for correct coding, appropriate billing, and reimbursement.


• Completes clinical reviews related to Claims, Claim Edits, Appeals and the Grievance process, assisting in analysis of clinical risk related to Underwriting, Pharmacy, and Finance departments.


• Recommends recovery efforts based on current contracts, policies, procedures and accepted industry standards.


• Reviews and validates pended and reconsidered claims when edits are applied by the Plan claim editing software from multiple vendors. Reviews are typically based on CPT guidelines, industry standards and CMS guidelines.


• Completes reviews on inpatient and outpatient high dollar claims following internal guidelines. Assists in reviews of quality concerns.


• Validates claim payments based on Plan contracts, often working with the Pharmacy team and the PNM department.


• Creates and maintains various reports to track department data.


• Assists in group discussions on challenging medical reviews.


• Assists with onboarding new team members as needed.


• Participates on selected workgroups and committees on an ad hoc basis as requested.

Work is typically performed in a work-from-home office which must be secure and follow HIPAA Privacy standards. 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.

Attend occasional onsite department meetings as needed.

*Relevant experience may be a combination of related work experience and/or completed specialty training program (1 year of specialty training = 1 year relevant experience).

CPC-Certified Professional Coder through AAPC, or CCS- Certified Coding Specialist through AHIMA required, LPN preferred.