Claims Configuration Medical Policy & Coding Specialist

Now hiring a Claims Configuration Medical Policy & Coding Specialist

A liaison role in the organization between different departments of the Presbyterian Health Plan (PHP) outpatient services. Manage collaboration among multidisciplinary teams to resolve from beginning to end - which may entail preparation, execution, feedback and resolution of claims, coding and system configuration. Responsible for the research, analysis, planning, implementation, evaluation, and development of Payment Integrity configuration by providing guidance and oversight for translating medical policies into rules that may promulgate from either external purchased criteria or in-house Medical Policy Manuals. Develops processes to meet responsibilities of configuration-based policies to ensure compliance is met and proper edits are in place with configuration departments.

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

• Full Time - Exempt: Yes
• Job is based at Rev Hugh Cooper Admin Center
• Remote work from home: this job is intended to be conducting in the state of New Mexico.
• Work hours: Days
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

 

Ideal Candidate:

Associates degree or higher in a related Health Information field.  5 years of experience in coding, researching medical coverage, and policy development. Experience with CPT, ICD-10-CM, HCPCS Level II coding rules and regulations, Medicare, AMA, and industry standards

• Associates degree or higher in a related Health Information field, OR
• Health Information Professional with at least 5 years of experience in medical coding, auditing, payer billing, and coding regulations.
• Minimum of 5 years of experience in coding, researching medical coverage, and policy development.
• Extensive knowledge of CMS Coverage guidelines, including Local Coverage Determinations (LCD), National Coverage Determinations (NCD), Fee Schedules, and coding edits such as National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs).
• Experience with CPT, ICD-10-CM, HCPCS Level II coding rules and regulations, Medicare, AMA, and industry standards.
•  
• Required Credentials:
• RHIT or RHIA or CPMA
• CPC, CCS and/or other AHIMA or AAPC coding specialty credential
• CPB or Claims and Billing Experience equivalent of Biller III or higher
• Experience with CPT, ICD-10-CM, HCPCS Level II coding rules and regulations, Medicare, AMA, and industry standards.

• Liaison between Medical Policy Committee (MPC), Medical Policy Manuals, Payment Integrity and configuration management systems.
• Develops and maintains configuration-based Medical Policies similar to Medical Policy Manuals based on MPC guidance and 3rd Party configuration policies, which may include a policy review similar to or in alignment with MPC policy decision.
• Develops and maintains process for research and policy configuration based on MPC or 3rd party guidance as well as Payment Integrity Committee (PIC) decision.
• Provides education and guidance, when needed, for multi-departmental coding configuration pertaining to CPT, HCPCS and ICD-10-CM when necessary to meet medical policy or payment integrity goals and needs.
• Verifies and Maintains policies to ensure Medicare, NCD and LCD, Medicaid, NMAC and LOD, Change Requests (CR) and Transmittals (TN) for CPT, HCPCS and ICD-10-CM are met and kept in compliance annually
• Provides oversight and assistance for coding configuration related to Payment Integrity for Medical Policy, external vendors, Medicare and Medicaid
• Liaison for internal departments Provider Relations and Payment Integrity configuration management systems pertaining to claims billing denials, to ensure edits meet mandates and appropriate coding guidelines including research and verification of PHP policies.
• Maintains and develops guidance documents outlining reoccurring inquiries and common requests received by Payment Integrity Committee (PIC).
• Collaborates and works as a liaison between external delegated vendors who provide billing and coding edits and various departmental leadership, such as escalated claims questions for denials and policy criteria.
• Works alongside Medical Standards Research Coordinators to develop, maintain and update written policies for the Payment Integrity Department and Committee under the direction or guidance of HealthPlan Medical Directors, Medical Policy Committee, Payment Integrity Committee and other departments as identified, including approved internal and external delegated vendors policy updates as needed from red line purchased criteria reviews, clinical determination, and various committee determinations.
• Maintains and modifies online external delegated vendors policies and configuration guidance for vendor edits to ensure completeness and accuracy for ease of use and clarity.
• Researches and resolves benefit or policy related questions for internal staff, which includes heading Payment Integrity, ad-hoc work groups, and conducting special sessions for coverage issues requiring immediate attention.
• Creates, submits and manages service requests (SR)s for configuration related to internal and external medical policies or regulatory guidance to ensure accurate claims edits are configured.
• Regularly reviews new HCPCS, CPT and ICD-10-CM codes quarterly update

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

USD $47.83/Hr.

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.