Claims Coding Analyst Senior

HealthPartners is hiring a Senior Coding Analyst provides business support in the proper use, code compliance and processing guidelines of insurance industry-standard coding, including CPT/HCPCS codes. The Senior Coding Analyst is responsible for ensuring the claims processing system accurately reflects active CPT-4, HCPCS, ICD-9, ICD-10 and other code sets to ensure HIPPA compliance. The Senior Coding Analyst will leverage system software and their industry and coding knowledge to support the evaluation of new codes, CMS or other state/government policy changes or plan specific policies. The Senior Coding Analyst investigates deficient claims to determine approval/denial status, payable reimbursement and to identify potential provider billing trends and errors. The Senior Coding Analyst ensures completion of necessary changes to the system as a result of edits to current code management procedures and facilitates necessary coding system configuration changes.

The Senior Coding Analyst administers, manages, supports and audits the vended code editing software and updates the claims processing system with new, revised and deleted CPT code pairs.

ACCOUNTABILITIES:

Provides expertise to all areas of the organization relating to coding questions including communication of new/deleted codes and coding policy changes

Monitors CMS, NUBC, and other agencies for transaction code set updates

Participates on internal coding committees

Represents HealthPartners and its interests in external industry forums at both the national and local level.

Facilitates testing and implementation of required system coding software updates

Resolves claim processing errors related to code validation edits during adjudication

Provides expertise in the evaluation of coding and transaction based business rules

Performs coding review to recommend new codes or deletion from all claims policy documentation

Acts as a key point of contact for claims, sales and contracting, researches all requests triggered from coding denials/provider appeals or adjustment requests

Performs daily review of deficient claims to determine proper coding and medical appropriateness

Approves or denies claims independently

Serves as the primary contact with the external coding software vendor for ongoing maintenance and customization

Communicates results of coding review to members and providers when appropriate

Develops and ensures coding software documentation is current and complete for business operational procedures, users and providers

Keeps accurate records of all coding changes for internal and external auditors

Collaborates, provides business support and proposes solutions to QUI/Medical Policy/Government Programs on member coverage criteria, code compliance and policy development

Performs trend analysis to evaluate provider reimbursement impacts, minimize inventory and increase revenue.

Serves as business coding architect to ensure edits achieve required business objectives

Works with Business System Analysts and Information Services Developers to research, evaluate, test and administer claims system enhancements and revenue generating code editing

Participates in the analysis, technical design, testing and integration of vended code editing software with HealthPartners' core claim processing system

Leadership responsibility to influence, train, mentor and provide work direction to team members as directed

REQUIRED QUALIFICATIONS:

Expert level proficiency and completion of Medical Coding Program and Certification (AAPC or equivalent) required, CPC, CCA, CCS

ICD-10 Certified

Demonstrated use of medical terminology, anatomy, physiology and disease processes as related to CPT4, HCPCS, Rev Codes, ICD9, ICD-10, 837P (HCFA 1500), 837I (UB - 1450) coding terms, methodologies and forms

5 years coding experience related to all types of patient visits

5 years' experience with HMO, fully insured and Indemnity products as well as government programs

Prior experience processing medical claims

Confident understanding COB (coordination of benefits) rules including Medicare regulations, policies and procedures

Computer literate and proficient using MicroSoft products and Encoder

5 years' experience using vended coding software products

Solid understanding of standard claims processing systems and data analysis

Excellent planning and organizational skills

Demonstrated depth of knowledge and experience in medical claims procedures, processes, governing rules and all aspects of claim adjudication

Ability to work and make logical decisions independently

Demonstrated analytical skills when performing trend analysis

Understanding of provider medical billing practices

Comfortable making difficult judgement calls

PREFERRED QUALIFICATIONS:

Bachelor's Degree in relevant field

7 + years' experience in the health care industry