Coding Specialist - Value-Based Reimbursement Expert

Description

We are seeking a dedicated Coding Specialist to join our team! In this role, you will serve as an internal expert on value-based reimbursement and medical policy models, ensuring their successful development and implementation. You will leverage your advanced knowledge to foster effective partnerships with provider entities, guiding them on capturing appropriate quality measures and utilizing CPT and ICD-10 codes accurately in claims submissions.

Your extensive coding expertise, combined with a solid understanding of medical policy, credentialing, and contracting rules, will be essential in creating effective guides and resources for providers. Your goal will be to maximize quality and STARs outcomes while maintaining payment integrity.

Skills

• Coding certification required (CPC certification preferred)
• Strong understanding of the authorization to claims process
• Ability to translate regulatory requirements into the authorization and claims configuration cycle
• Experience working with various lines of business (Medicare, Medicaid, Commercial, ASO, etc.)
• Detail-oriented with a strong understanding of CPT code groupings based on data and medical knowledge
  
  

Responsibilities

• Consult on proper coding rules within value-based contracts to ensure appropriate quality measure capture and correct use of CPT and ICD-10 codes.
• Provide input on the financial implications of various incentive models, supporting the use of alternatives and solutions to optimize quality payments and risk adjustments.
• Translate claims language into service descriptions for episode or capitated payments, clearly articulating inclusions and exclusions in models.
• Act as a technical resource and coding subject matter expert for contract pricing issues. Conduct business and operational analyses to ensure compliance with contracts and identify areas for improvement.
• Offer problem-solving expertise on system issues, particularly when codes are not accepted.
• Troubleshoot and make recommendations on complex coding and billing issues, whether they are systemic or isolated.
• Contribute to the development and refinement of guides and resources for providers, focusing on expected methodologies for billing and code submissions to enhance quality outcomes and maintain payment integrity.
• Engage directly with provider groups during proactive training events or provide just-in-time assistance on complex claims matters.
• Collaborate with various teams, including Practice Transformation Consultants, Medical Policy Analysts, and Provider Network colleagues, to interpret coding and documentation language and address provider inquiries.
• Stay current with coding rules and standards to ensure compliance and accuracy.
  
  

If you are passionate about coding and want to make a meaningful impact in the world of value-based reimbursement, we would love to hear from you!

Employment Type: Full-Time