Senior Medical Coding Specialist (Remote) Payment Integrity

CareFirst; Baltimore (MD); Remote; USD 67,000 - 134,000; Full time

Job summary

CareFirst, Inc. is hiring a Senior Medical Coding Specialist to serve as an internal expert ensuring proper use of CPT and ICD-10 codes in claims, and to support value-based reimbursement models within Payment Integrity.

You will collaborate with provider groups and internal teams to interpret coding rules, develop guidelines, and mentor staff while staying current on industry standards and policies.

Qualifications

• Knowledge of billing practices for hospitals/physicians and contracting/claims processing.
• Experience in revenue cycle management and value-based reimbursement/contracting models and methodologies.
• Detail-oriented with ability to manage multiple projects simultaneously.
• Excellent written and verbal communication skills.
• Ability to analyze and present data effectively.
• Ability to create educational materials/training manuals/guides.
• Experience with Microsoft Office and data-tracking tools.

Responsibilities

• Consults on proper coding rules in value-based contracts to ensure quality capture and correct use of CPT/ICD-10 codes.
• Acts as coding SME for contract pricing issues and performs complex analyses to ensure compliant payments.
• Develops guides/resources for providers on billing methodologies to maximize STARs outcomes while maintaining integrity.
• Collaborates with internal teams to interpret coding/documentation language for provider inquiries.
• Mentors less experienced staff and shares industry trend insights.
• Maintains up-to-date knowledge of coding standards and regulatory changes.

Skills

Billing knowledge

Value-based reimbursement

Data analysis

Communication skills

Project management

Educational material creation

Attention to deadlines

Education

Bachelor’s degree

Tools

Microsoft Office

Job description

Resp & Qualifications

PURPOSE:
The Senior Medical Coding Specialist acts as an internal expert to ensure that value-based reimbursement and medical policy models are developed and implemented to support Payment Integrity. This role provides expert knowledge to support effective partnership with provider entities, guidance on the appropriate quality measure capture and proper use of CPT and ICD 10 codes in claims submissions. This role utilizes coding expertise, combined with medical policy, credentialing, and contracting rules knowledge, to build effective guidelines and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity. This role will also provide expertise and mentoring to other team members. This role will sit within the Payment Integrity team.
ESSENTIAL FUNCTIONS:

• Consults on proper coding rules in value-based contracts to ensure appropriate quality measure capture and proper use of CPT and ICD10 codes. Provides expertise on various consequences for different financial and incentive models. Strategizes alternatives and solutions to maximize quality payments and risk adjustment. Translates from claim language to services in an episode or capitated payment to articulate inclusions and exclusions in models.
• Serves as a technical resource / coding subject matter expert for contract pricing related issues. Conducts complex business and operational analyses to assure payments are in compliance with contract; identifies areas for improvement and clarification for better operational efficiency. Provides problem solving expertise on systems issues if a code is not accepted. Troubleshoots, make recommendations and answer questions on more complex coding and billing issues whether systemic or one-off.
• Develops and refines effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity. May interface directly with provider groups during proactive training events or just in time on complex claims matters. Consults with various teams, including the Practice Transformation Consultants, Medical Policy Analysts and Provider Networks colleagues to interpret coding and documentation language and respond to inquiries from providers.
• Participates in strategy and contributes to thought leadership for quality measure capture (NCQA, HEDIS, STARs). Collaborates with internal stakeholders on process and outcome improvement activities. Ensure compliance with all coding standards.
• Facilitates mentorship, providing assistance to less seasoned team members.
• Actively researches industry trends, keeping up-to-date and maintaining a high level of expertise in coding rules and standards.

SUPERVISORY RESPONSIBILITY

Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.

Education Level: Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications Upon Hire Required:

• CCS-Certified Coding Specialist or
• Certified Coder (CCS or CPC)-AHIMA or AAPC

Experience: 5 years' experience in risk adjustment coding, ambulatory coding and/or CRC coding experience in managed care; state or federal health care programs; or health insurance industry experience

Preferred Qualifications

• Certified public accountant
• Experience in medical auditing
• Experience in training/education/presenting to large groups

Knowledge, Skills and Abilities (KSAs)

• Knowledge of billing practices for hospitals, physicians and/or ancillary providers as well as knowledge about contracting and claims processing.
• Experience in revenue cycle management and value-based reimbursement/contracting models and methodologies.
• Detail-oriented with an ability to manage multiple projects simultaneously.
• Excellent communication skills both written and verbal.
• Demonstrated ability to effectively analyze and present data.
• Ability to create educational materials, training manuals, and/or procedural guides.
• Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and demonstrated ability to learn/adapt to computer-based tracking and data collection tools, Proficient.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $67,464 - $133,991

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of theCompany to provide equal employment opportunities to allqualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship