Senior Medical Coding Specialist (Remote) Payment Integrity

Senior Medical Coding Specialist (Remote) Payment Integrity in Baltimore, MD - CareFirst

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Senior Medical Coding Specialist (Remote) Payment Integrity

Job ID: 22223

Job Function: Medical Management

Location: Baltimore, MD

Office: Canton Crossing

Career Band: BDB

Status: Full-Time

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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 the Company to provide equal employment opportunities to all qualified 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

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Serving Maryland, the District of Columbia, and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the shared business name of CareFirst Advantage, Inc., CareFirst Advantage PPO, Inc. and CareFirst Advantage DSNP, Inc. CareFirst BlueCross BlueShield Community Health Plan Maryland is the business name of CareFirst Community Partners, Inc. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst Advantage, Inc., CareFirst Advantage PPO, Inc., CareFirst Advantage DSNP, Inc., CareFirst Community Partners, Inc., CareFirst BlueCross BlueShield Community Health Plan District of Columbia, CareFirst BlueChoice, Inc., First Care, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

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

Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. To comply with this law, CareFirst must collect information regarding an employee's identity and employment eligibility and document that information on a document referred to as Form I-9, Employment Eligibility Verification, no later than three business days from when the employee begins work for pay. If you are hired, you will be required to provide certain information on the form necessary to establish your identity and eligibility to work in the United States and certain required supporting documents.

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The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c) If you believe that you have experienced discrimination, contact OFCCP at 800-397-6251 (TTY 877-889-5627) or www.dol.gov/ofccp.