Coder Specialist - Special Investigations Unit (SIU)
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POST DATE 8/30/2016
END DATE 10/15/2016
JOB DESCRIPTIONAPPLY Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment while still being valued for your individual strengths Health Choice is the place for you.
Equal Opportunity Employer Minorities/Women/Veterans/Disabled
JOB SUMMARY: As part of the Compliance Department Special Investigations Unit (SIU) team, the primary duty of the position is to perform reviews of (i) claim lines flagged by the Health Choice payment accuracy vendor (Vendor) and (ii) case referrals involving suspected upcoming and unbundling.
1.Conduct reviews of flagged claim lines and referrals involving suspected up coding and unbundling.
*Review claim lines flagged by Vendor with do not pay recommendations;
*Review case referrals from the Vendor involving suspected up coding and unbundling.
*Conduct outreach to physicians and office staff for medical records when needed to support review of flagged claims and/or case referrals;
*Communicate with physicians and office staff on needed documentation or clarification on coding and/or billing requirements.
2.Initiate, coordinate, and schedule education/training in-services and seminars with contracted providers, Health Choice Staff and other stakeholders.
*Organize in-services, meetings or seminars with providers, Health Choice Staff and other stakeholders to provide general and targeted training in response to issues identified during the review of claim lines and case referrals.
3.Report outcomes on the review of claim lines with Vendor do not pay recommendations and suspected case referrals (e.g. up coding and/or unbundling).
*Develop, maintain and send routine/recurring production reports showing status of cases received and their disposition, including the aging of case referrals
received and those for which medical records from a provider are required.
4.Report outcomes on the review of claim lines with Vendor do not pay recommendations and suspected case referrals (e.g. up coding and/or unbundling).
*Assist with cross Departmental efforts to implement timely changes to claim system edits, benefit configuration and/or prior authorization requirements, as warranted.
*Timely review to confirm whether a do not pay recommendation from the Vendor on a claim line is appropriate based on regulatory and industry coding and/or billing requirements and standards.
*Timely review and disposition of suspected case referrals, including determination on alleged up coding and/or unbundling and participation in any actions items identified in connection with a confirmed unbundling and/or up coding incident.
*Provide technical assistance on cases where Health Choice considers whether to accept a Vendor recommendation selectively for one provider or group or systematically for all Providers.
*Complete quality, accuracy and inter-rater reliability testing on claim line reviews as requested in a timely manner.
*Abide by all HIPAA and associated patient confidentiality requirements
*Communicate review outcomes and the basis for them effectively and professionally with providers, Health Choice Staff and other stakeholders
*Provide feedback to appropriate departments on provider education needs.
*Conduct in person or telephonic education and training on regulatory and industry coding and/or billing requirements and standards in connection with claim reviews
*Timely and accurate production reporting on a daily, weekly, monthly, quarterly and annual basis, including both flagged do not pay recommendations and disposition of case referrals
*Timely and accurate implementation of changes to claim system edits, benefit configuration and/or prior authorization requirements.
Professional Competencies (knowledge, skills, and abilities):
*Microsoft Windows applications.
*Knowledge of Medicaid and Medicare programs.
*Knowledge of Commercial health plan programs.
*Strong customer service skills and techniques.
*Strong presentation, oral and written communication skills.
*Strong knowledge of risk adjustment/HCC coding
*Ability to effectively interact with staff, customers and management at all levels.
*Clinical training (Medical Assistant, Registered Nurse, Licensed Practical Nurse, or Certified Nursing Assistant) preferred
*College degree preferred
*At least two (2) years of Clinical experience; prefer experience in performing chart abstractions
Certification and License:
*Certified Coder, Medical Billing and Coding certification required.
Job: Quality Management Analyst
Primary Location: Arizona-Phoenix
Organization: Health Choice
Education Level: High School Diploma/GED
Employee Status: Full Time Benefit Eligible 36-40 hrs/wk
Work Schedule: Days