Wellmark Blue Cross and Blue Shield · 1 month ago
Health Services Coding Analyst (CPC Required)
United States
Full-time
Remote
Lead/Staff
7+ years expWellmark Blue Cross and Blue Shield is a mutual insurance company focused on the well-being of its members. The Health Services Coding Analyst will provide clinical leadership and expertise in the analysis and administration of medical policy content, ensuring compliance and accuracy within claims processing systems while collaborating with various teams to resolve coding-related issues.
FinanceHealth InsuranceProperty & Casualty InsuranceWellnessFinancial ServicesInsurancePersonal Health
No H1B
Responsibilities
Lead the analysis of the most complex Wellmark medical policy content and implementation of system edits to support its intent. Medical policy coding requirements are implemented, tested, documented and audited to assure compliance
Maintain the claims processing system infrastructure to ensure compliance with regulatory and accreditation bodies and vendor supported technical requirements and ensure accurate claims adjudication
Translate complex medical policy language into precise, actionable coding criteria for integration into claims systems and configuration platforms
Serve as coding subject matter expert for complex or escalated utilization management
Collaborate with Utilization Management nurses, medical directors, and claims teams to resolve coding-related denials, overrides, and policy interpretation questions
Contribute to the full lifecycle of medical policy creation, revision and interim review, including drafting coding sections, researching emerging procedures/devices, and ensuring policies reflect current coding conventions (AMA CPT, ICD10, HCPCS)
Conduct impact analyses of proposed policy changes on coding, reimbursement, and operational workflows
Work directly with Health Services leadership, Medical Review staff, leadership within Claims and Customer/Provider Services and Network Engagement, Medical Directors to provide medical coding expertise and PGE rule knowledge to resolve complex claims and/or customer and provider issues
Maintain coding integrity by monitoring utilization trends to identify and resolve system configuration issues
Work with Medical Policy Leadership in the development and optimization of coding configuration standards and best practices
Work with payment integrity, business support, and data analytics teams to edit, develop, and implement Optum, Cotiviti, and Cognizant edits
Contribute to the achievement of corporate and UM Product Team objectives by independently serving as primary points of contact and UM Product Team Subject Matter Expert/Guest Star to provide expertise to support the various claims processing systems, including but not limited to PGE rules and table maintenance (FACETS and STAR). This will include attendance to various virtual cross-functional team meetings, as well as in-person attendance and participation in quarterly Iteration Planning meeting
Update coding files as required by code set revisions, HIPAA-AS, medical policy development and implementation, regulatory requirements, FEP and Blue Card guidelines, or as needed to support other internal processes
Participate in cross functional meetings or initiatives to support the goal of managing medical benefit expense
Provide expertise in the areas of medical coding PGE rule knowledge and medical policy configuration rules to support projects and broad organization initiatives. Consult with leadership as business decisions are made and retain and archive documentation of decisions made. Comply with regulatory standards, accreditation standards and internal guidelines; remain current and consistent with the standards pertinent to the Medical Policy team
Mentor and train Coding Specialist as well as provide specific topic training related to medical policy administration/PGE rules to other operational areas such as customer and provider service as needed
Other duties as assigned
Qualification
Required
Associate degree or direct and applicable work experience preferred
Certified Professional Coder (CPC) required
Clinical background which may include either formal education or training in a clinical or health-related discipline (such as nursing, medical assisting, surgical technology, health information management, or a related field) and/or direct work experience in a clinical or healthcare setting
7+ years' or related health care experience in provider payment, claims, medical coding, or similar
Demonstrated expertise and knowledge of medical coding and terminology
Demonstrated strong attention to detail with the ability to multitask
Strong interpersonal skills including clear and concise written and verbal communication
Inquisitive nature, enthusiastic about developing and enacting new processes
Strong workflow management skills with sense of ownership, drive and initiative to continuously improve outcomes
Ability to communicate concepts clearly and concisely to individuals and groups and motivate others to achieve success with an eye toward promoting a culture of collegiality and excellence
Demonstrated ability to obtain relevant information by relating and comparing data from different sources
Proficiency in Microsoft Office applications including experience with spreadsheets, process mapping, presentation and word processing
Ability to adhere to quality and production metrics
Some experience with and continued interest in coaching and mentoring others
Demonstrated ability to consistently meet department work schedule
Preferred
Prior health plan experience
Benefits
Remote Eligible *see job footer for more info
You will have the flexibility to work where you are most productive. This position is eligible to work fully remote. Depending on your location, you may still have the option to come into a Wellmark office if you wish to. Your leader may ask you to come into the office occasionally for specific meetings or other ‘moments that matter’ as well.
Company
Wellmark Blue Cross and Blue Shield
Wellmark is a leading health insurance company committed to making health care coverage more affordable and good health more attainable for everyone we serve. For more than 85 years, Wellmark has used our strong local connections and expertise to empower our members with personalized, high-quality coverage.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
John Forsyth
Chief Executive Officer
Andrew Neller
Deputy Chief Information Security Officer
Recent News
2022-02-18
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