Medical Biller and Coder

Greenkey Resources LLC; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

Join a forward-thinking company dedicated to ensuring compliance and quality in healthcare services. In this role, you will analyze and resolve sensitive appeals and coding disputes, ensuring adherence to regulatory guidelines while providing comprehensive responses. With a focus on quality and efficiency, you will collaborate with medical directors and contribute to maintaining high standards set by accreditation agencies. If you have a passion for healthcare and a knack for analytical problem-solving, this opportunity is perfect for you.

Qualifications

• Bachelor’s degree or advanced degree where required.
• 3 years of related experience or 5 years in lieu of degree.

Responsibilities

• Analyze and resolve appeals, coding disputes, and grievances.
• Prepare files for external reviews and document investigations.
• Monitor reports to ensure compliance with regulations.

Skills

Analytical Skills

Judgment and Decision Making

Communication Skills

Medical Terminology

Education

Bachelor’s Degree

CPC Certification

Job description

Responsibilities

• Analyze, research, resolve and respond to confidential/sensitive appeals, coding disputes, grievances and coverage/organization determinations from members, member's representatives, providers, media outlets, senior leadership andregulatory agencies with established regulatory and accreditation guidelines.
• Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providers.
• Regularly and independently exercise judgement to make appropriate decisions based on policies and guidelines.Acts decisively to ensure business continuity and with awareness of all possible implications and impact.
• Prepare files and develops position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants.
• Provide comprehensive appeals, coding disputes and grievances responses that support the decision and comply with regulatory and accreditation guidelines.
• Document extensive investigation, relative findings, and actions in all applicable systems
• Accountable for monitoring daily reports to ensure service timeliness and compliance is met.
• Gather clinical information by using established criteria provided in corporate medical policies; partner with Medical Directors who are responsible for all decisions regarding clinical appeals/grievances.
• Ensures timeliness, quality, and efficiency in all work to comply with applicable mandated State (NCDOI) and/or Federal (Centers for Medicare & Medicaid Services (CMS), ERISA, etc.) accreditation agency standards (National Committee for Quality Assurance – NCQA), ASO group performance guarantees

Qualifications

• Bachelor’s degree or advanced degree where required.
• 3 years of related experience
• In lieu of degree, 5 years of related experience
• CPC required