Medicare Specialist

Prime Health Services; Franklin (TN); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Medical Insurance (HDHP with HSA)

Dental Insurance

Vision Insurance

Disability Insurance

Group term life insurance

Generous PTO Policy

Employee recognition programs

Office amenities

Regular employee events

Job summary

Prime Health Services is seeking a Medicare Specialist in Franklin, TN to research, maintain, and create methodologies for Medicare payment systems across our product suite. The role requires interpreting ICD-10CM, CPT4, and Medicare policies, and drafting clear procedures for payment calculations.

You will collaborate with Regulatory Compliance, draft user stories, maintain internal docs, and ensure timely delivery while handling multiple priorities and deadlines.

Qualifications

• Bachelor's Degree in health care administration or related discipline.
• Outpatient Coding Credential (CPC/COC/CCS-P) preferred.
• Proficient with Microsoft Office (Excel/Word/PowerPoint).
• 2+ years of relevant work experience preferred.
• Knowledge of ICD-10CM, CPT4, Revenue Codes, DRGs, HCPCS, and Medicare rules.

Responsibilities

• Research and decipher complex Medicare payment rules for multiple products.
• Collaborate with Regulatory Compliance on reimbursement for PIP/Workers Comp.
• Draft concise documentation and translate into user stories and project plans.
• Create and update internal Medicare product documentation and processes.
• Identify issues and communicate clearly to team members and leadership.
• Manage competing priorities and meet deadlines with quality analyses.
• Develop, manage, and maintain Medicare policy rules in PHS software.
• Report showstopper issues to the Director of Compliance.
• Perform unit and acceptance testing as necessary.
• Perform other duties as assigned.

Skills

Analytical ability

Communication skills

Problem solving

Independent work

Education

Bachelor's Degree in health care administration or related field

Tools

Microsoft Office Suite

Job description

About this position

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.

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