Senior Medical Coding Specialist (Remote)

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.

Responsibilities

• 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.
• 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.
• Collaborates with internal stakeholders on process and outcome improvement activities.
• Ensures compliance with all coding standards.
• Facilitates mentorship, providing assistance to less seasoned team members.

Qualifications

• 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: 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.