Medicare Specialist

Prime Health Services, Inc.; Franklin (TN); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Disability insurance

Life insurance

Generous PTO

Employee events

Job summary

Prime Health Services (PHS) is seeking a Medicare Specialist to research and implement Medicare payment system methodologies within our product suite. You will work with Regulatory Compliance to apply Medicare rules to PIP and Workers' Compensation reimbursements and draft clear documentation for payment procedures.

The role involves maintaining Medicare policy rules in our bill review software, performing testing, and communicating issues to the Director of Compliance.

Qualifications

• Bachelor's degree in health care administration or related field. Related health care admin experience may substitute.
• Outpatient Coding Credential (CPC/COC/CCS-P preferred).
• Proficient with Microsoft Office (Excel, Word, PowerPoint).
• 2+ years in healthcare setting preferred (physician practice, hospital, payer, or IDN).
• Knowledge of ICD-10CM, CPT4, Revenue Codes, DRGs, HCPCS, Medicare rules and OPPS.

Responsibilities

• Researches and deciphers complex legal and regulatory sources regarding Medicare payment rules.
• Collaborates with Regulatory Compliance on Medicare rules for Personal Injury Protection and Workers Compensation.
• Drafts concise documentation for payment procedures and translates them into user stories and project plans.
• Creates and updates internal documentation for Medicare products.
• Identifies issues and communicates clearly to team and leadership.
• Manages priorities and delivers high-quality information while meeting deadlines.
• Develops and maintains rules in PHS bill review software for Medicare policies.
• Reports showstopper issues to the Director of Compliance.
• Performs unit and acceptance testing as necessary.
• Performs other duties as assigned.

Skills

Healthcare administration

Medical coding knowledge

ICD-10CM knowledge

CPT4 knowledge

Office software

Problem solving

Education

Bachelor's Degree in health care administration

Tools

Microsoft Office Suite

Job description

Description

The Medicare Specialist researches, maintains, updates and creates new methodologies for Medicare payment systems to implement in Prime Health Services' (PHS) suite of products as appropriate and understands NCCI/MUE billing edits as related to Prime products.

What You'll Do

• Researches and deciphers complex legal and regulatory sources regarding payment rules for Medicare payment systems
• Collaborates with Regulatory Compliance colleagues on how Medicare rules apply to Personal Injury Protection and Workers Compensation reimbursement
• Drafts concise documentation for payment procedures- including payment calculation logic- and interacting with the development team to refine that documentation into user stories and project plans
• Creates and updates internal documentation and processes, as needed for all Medicare based products
• Identifies issues upfront and communicate clearly to team members and leadership
• Manages competing priorities and delivers quality information and analysis while adhering to deadlines
• Develops, manages, and maintains rules in the PHS proprietary bill review software for all Medicare payment policies and systems
• Reports any showstopper issues to the Director of Compliance
• Performs unit and acceptance testing as necessary
• Performs other duties as assigned

Requirements

• Bachelor's Degree in health care administration, business and/or other related discipline (Related experience in a health care administration setting may be substituted for educational requirements)
• Outpatient Coding Credential (Certified Professional Coding (CPC), Certified Outpatient Coder (COC), or Certified Coding Specialist- Professional (CCS-P) are preferred
• Proficient computer skills - expert knowledge of Microsoft Office Suite (Excel, Word, PowerPoint)
• 2+ years of relevant work experience (physician practice, hospital, ancillary provider, health insurance company or integrated delivery system) is preferred
• Knowledge of ICD-10CM, CPT4, Revenue Codes, DRGs, base rates, HCPCS coding, Medicare regulations, payment policies, OPPS, and related governmental guidelines and provider reimbursement methodologies are required

Competencies

• Excellent planning, communication (oral and written), documentation, and organizational abilities
• Advanced mathematical, analytical, and problem-solving skills
• Ability to interpret and summarize results of various analyses in a timely and meaningful way
• Ability to work cooperatively with multidisciplinary teams and/or independently

Why You'll Love Working At PHS

• Medical Insurance (high deductible plan with an HSA)
• Dental Insurance
• Vision Insurance
• Short-term and long-term disability paid by the company
• Group term life paid by the company
• Generous PTO Policy
• Employee recognition programs
• Corporate office amenities
• Regular employee events

About PHS

Prime Health Services (PHS) is a national medical cost containment company with a noteworthy PPO Network used by insurance carriers, TPA's, self-insureds, and governmental entities. Our tech-focused nature allows clients to take advantage of the flexibility of customization while not compromising on bill processing speed. Since 2001, we have specialized in medical provider network development and offer clients a tailored approach to medical cost containment: quality health care at discounted rates.