Claim Edit and Vendor Integrity Specialist, Geisinger Health Plan (Pennsylvania resident)
Job Summary
Acts as a leader, liaison, and resource working collaboratively with a diverse group, including management, physicians, clinical and non-clinical personnel utilizing the national correct coding standards, approaches, and industry standard coding rules to support and expand internal and external strategies.
Job Duties
Minimum one certification required:
- Certified Professional Coder CPC through AAPC
- Certified Professional Biller through AAPC
- Applies expanded knowledge of CPT, ICD-10 and HCPCS coding skillstoward the maintenance and development of prospective claim edits and partnerships.
- Determines payment compliance with clinical and reimbursement policies.
- Researches CPT codes to clarify coding issues, as required.
- Determines opportunities with current vendor partnerships and implementations, exploring new opportunities as well.
- Coordinates, reviews, and recommends changes for the yearly opportunity analysis.
- Reviews and responds to claim edit appeals and rational requests.
- Coordinates, supports, and resolves vendor needs both prospectively and retrospectively.
- Problem solves system/claim edit issues that may come up.
- Tests and verifies new claim edits as a component of maintenance and during implementation for new vendors
- Leads the Edit Expansion Committee as a component
- Leads routine maintenance and oversight meetings with vendor partners
- Acts as a subject matter expert in support of internal workgroups/committees, etc.
- Interacts with providers and/or Account Managers to clarify documentation and billing issues identified.
- Leads internal development, testing, maintenance, and expansion of internal claims edits.
- Leads the development of the ClaimsXten Policy Management Module.
- Mentors less experienced staff and new hires.
- Compiles and coordinates routine performance reporting for various vendor initiatives and supports various report out meetings.
Work is typically performed in an office environment. 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. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Position Details
Minimum one certification required:
- Certified Professional Coder CPC through AAPC
- Certified Professional Biller through AAPC
Education
High School Diploma or Equivalent (GED)- (Required), Graduate from Specialty Training Program- (Preferred)Experience
Minimum of 5 years-Related work experience (Required), Minimum of 5 years-Health Insurance/Managed Care (Preferred)Certification(s) and License(s)
Certified Professional Coder - American Academy of Professional Coders (AAPC); Certified Professional Biller - American Academy of Professional Coders (AAPC)About Geisinger
Founded more than 100 years ago by Abigail Geisinger, the system now includes ten hospital campuses, a 550,000-member health plan, two research centers and the Geisinger Commonwealth School of Medicine. With nearly 24,000 employees and more than 1,700 employed physicians, Geisinger boosts its hometown economies in Pennsylvania by billions of dollars annually. Learn more at geisinger.org or connect with us on Facebook, Instagram, LinkedIn and Twitter.
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.
Our Vision & Values
Everything we do is about making better health easier 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.
Our Benefits
We offer healthcare benefits for full time and part time positions from day one, including vision, dental and prescription coverage.
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