Coding and Reimbursement Specialist

About the Role

This is a remote, full-time position with MediGold, a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. The Coding and Reimbursement Specialist responds to post-payment inquiries from providers regarding claim disposition, serves as a department resource, provides and develops educational resources for providers, and acts as the subject matter expert for the Plan in all matters related to provider billing and reimbursement.

Responsibilities

• Review and respond to post-payment inquiries from providers.
• Process pended claims to ensure integrity of claim payment to providers and members.
• Work with provider credentialing to ensure proper set-up for accurate payments.
• Process and review requests from members for reimbursement.
• Proactively identify, through auditing and internal reporting, trends; develop and present reports of findings to Health Plan leadership.
• Develop and maintain effective working relationships with providers and their billing staff.
• Perform responsibilities of Claims Auditor as time and workload permit.
• Assist in the development of tools and presentations on documentation, coding, billing, and other topics of interest to the provider community.
• Attend coding and billing conferences, workshops, and in-house education sessions to stay current with regulations.
• Analyze claims processes to identify potential areas of fraud, waste, and abuse; provide recommendations to improve processes.
• Assist with the release of claims pended for coding issues.

Requirements

• High School degree required; Bachelor's degree preferred.
• CPC, CPC-P, or equivalent certification preferred.
• Minimum of 5 years of experience in claims auditing, billing, and/or coding.
• In-depth knowledge of current Medicare coding and billing requirements.
• Knowledgeable in multi-specialty coding and billing requirements.
• Extensive knowledge of auditing concepts and principles.
• Advanced knowledge of current medical terminology, anatomy, and physiology.
• Advanced knowledge of current ICD-10, CPT-4, and HCPC coding principles and documentation guidelines.
• Extensive knowledge of Medicare regulations and policies pertaining to documentation, coding, and billing.
• Strong written and verbal communication skills to clearly articulate complex regulatory information to internal and external customers, including physicians, practice managers, and billing staff.

Benefits

• Competitive compensation and benefits packages, including medical, dental, and vision coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition and professional development reimbursement.
• Relocation assistance (geographic and position restrictions apply).
• Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing.
• Employee Referral Rewards program.
• DailyPay: Access earned wages before payday.
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.