Medical Policy & Claims Implementation Specialist

Geisinger; Pennsylvania; Remote; USD 65,000 - 95,000; Full time

Job summary

Geisinger is seeking a coding and claims specialist to help ensure accurate CPT/HCPCS coding, medical claims validation, and benefit configuration. The role involves coordinating with benefits systems analysts to align codes with policy changes and regulatory directives.

You will conduct retrospective medical claims reviews, validate services billed, and research reimbursement and documentation needs. Strong attention to detail and regulatory knowledge are essential.

Qualifications

• Experience with CPT/HCPCS coding and medical claims review.
• Ability to validate services billed to the medical benefit and ensure compliance.
• Familiarity with government directives and policy development.

Responsibilities

• Provide direction to benefits systems analysts for correct configuration by business line.
• Conduct research and retrospective review of medical claims for regulatory compliance.
• Review medical records to validate services billed with codes.
• Research reimbursement, documentation, utilization and coding.
• Review clinical documentation to determine coverage eligibility.
• Recommend system setup changes for proper claims adjudication.
• Maintain databases cataloging code status related to policy and mandates.
• Audit claims and identify areas to reduce financial liability.
• Assist in coding updates and annual code implementations across departments.
• Present findings to committees regarding benefits and claims configuration.
• Produce ad hoc reports on pre- and post-implementation utilization.

Skills

CPT coding

HCPCS coding

Medical claims

Benefit configuration

Policy development

Data analysis

Tools

Facets workflow

Job description

Geisinger is seeking a coding and claims specialist to help ensure accurate CPT/HCPCS coding, medical claims validation, and benefit configuration. The role involves coordinating with benefits systems analysts to align codes with policy changes and regulatory directives.

You will conduct retrospective medical claims reviews, validate services billed, and research reimbursement and documentation needs. Strong attention to detail and regulatory knowledge are essential.