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Community Health Options · 3 weeks ago

Policy and Coding Research Specialist

United States

Full-time

Remote

Mid Level

3+ years exp

Community Health Options is a health plan dedicated to providing excellent medical care. The Policy and Coding Research Specialist is responsible for translating evidence-based medical care into policies and procedures, conducting research on clinical and regulatory resources, and collaborating with various teams to ensure proper code configuration and compliance.

Health CareInsuranceNon Profit

Responsibilities

Reviews clinical resources and external health plan policies for coverage comparisons

Supports review of CMS-designated codes, coding updates and does timely review of codes initially designated as exclude at launch or experimental/investigational to determine required code designations. Works closely with the Coding and Configuration Manager to accomplish this

Does research needed for custom code-configuration lists, such as the Chronic Illness Support Program, to support all lines of business and self-insured employer groups benefit coverage requirements, as applicable

Monitors regulatory requirements to ensure appropriate code configuration and coverage

Is part of the Utilization Management Team that supports and collaborates with the Clinical Operations Team to ensure appropriate configuration of codes for billing and auditing

Participates in the Clinical Code Review, Benefits and other Committees as requested

Works with Compliance Team to meet regulatory requirements and stay up to date on legislative initiatives

Is responsible for updating policies and guidelines within MCG and maintains the license and relationship with our vendor partner

Maintains the licenses and communication with Hayes (symplr) Medical Necessity Guidelines

Maintains expert knowledge of ICD-10 and 11, CPT and HCPCS codes and provides education as necessary

Understands current Member Benefit Agreements for all lines of business

Willingness to support the Utilization Management team with case reviews as needed to maintain compliance

Willingness to participate in project work or supportive duties as assigned by the Director of Utilization Management, Care Management and UM Appeals, the Coding and Configuration Manager, or Senior Medical Director

Qualification

RN LicensurePolicy research experienceCertified coderMedical necessity reviewsICD-10/11 knowledgeCPT knowledgeMCG Guidelines familiarityMicrosoft WordMicrosoft ExcelSalesforce adaptabilityEnglish communication