Job Description

Location:

Work from home (Pennsylvania)

Shift:

Days (United States of America)

Scheduled Weekly Hours:

40

Worker Type:

Regular

Exemption Status:

No

Job Summary:

Contributes to the achievement of the strategic and financial goals of the organization by conducting thorough reviews of billed services, authorizations, plan benefit documents, itemized statements, medical records, discharge summaries and detailed data reports. Makes reimbursement or recovery recommendations based on appropriate coding, billed statistics, policies, industry standards and compliance with contractual, state, and federal regulations.

Job Duties:

• Supports and serves as a resource to other Health Plan departments by providing review and recommendation for correct coding, appropriate billing, and reimbursement.
• Completes clinical reviews related to Claims, Claim Edits, Appeals and the Grievance process, assisting in analysis of clinical risk related to Underwriting, Pharmacy, and Finance departments.
• Recommends recovery efforts based on current contracts, policies, procedures and accepted industry standards.
• Reviews and validates pended and reconsidered claims when edits are applied by the Plan claim editing software from multiple vendors. Reviews are typically based on CPT guidelines, industry standards and CMS guidelines.
• Completes reviews on inpatient and outpatient high dollar claims following internal guidelines. Assists in reviews of quality concerns.
• Validates claim payments based on Plan contracts, often working with the Pharmacy team and the PNM department.
• Creates and maintains various reports to track department data.
• Assists in group discussions on challenging medical reviews.
• Assists with onboarding new team members as needed.
• Participates on selected workgroups and committees on an ad hoc basis as requested.

Work is typically performed in a work-from-home office which must be secure and follow HIPAA Privacy standards. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

Position Details:

Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Attend occasional onsite department meetings as needed.

*Relevant experience may be a combination of related work experience and/or completed specialty training program (1 year of specialty training = 1 year relevant experience).

CPC-Certified Professional Coder through AAPC, or CCS- Certified Coding Specialist through AHIMA required, LPN preferred.

Education:

High School Diploma or Equivalent (GED)- (Required), Graduate from Specialty Training Program- (Preferred)

Experience:

Minimum of 3 years-Relevant experience* (Required), Minimum of 2 years-Clinical (Preferred)

Certification(s) and License(s):

Certified Coding Specialist - American Health Information Management Association (AHIMA), Certified Professional Coder - American Academy of Professional Coders (AAPC)

Skills:

Computer Literacy, Critical Thinking, Organizing

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities.

• KINDNESS: We strive to treat everyone as we would hope to be treated ourselves.
• EXCELLENCE: We treasure colleagues who humbly strive for excellence.
• LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow.
• INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
• SAFETY: We provide a safe environment for our patients and members and the Geisinger family.

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.