Develop and manage clinical benefit configuration process to ensure timely and accurate claims payment system configuration and claim processing. Responsible for the codification and mapping of benefit product building, including the development and maintenance of the benefit configuration document and attaching appropriate service rules required for each benefit category. Serve as subject matter expert in all areas of the medical plan configuration, medical utilization edits, service payment limits and service rules. Develop workflows and business processes to ensure timely and accurate system build. Act as a facilitator to accurately translate product benefit and all aspects of the service rules into a configurable document. Provide business requirements to CORE configuration for purposes of translating clinical concepts into system configuration requirements. Provide guidance to employees and providers regarding documentation concerns as they relate to coding and billing.
This is a remote position.
Job Description
· Develop workflows and business processes to ensure timely and accurate clinical claims payment system configuration (benefit configuration)
· Translate clinical product benefits and all aspects of the service rules for system configuration
· Provide business requirements to CORE configuration for benefit build
· Support quality review and testing of all benefit setup prior to implementation and go-live
· Partner with Product, IT Claims and Compliance departments to audit setups and configuration post go-live
· Conduct testing and auditing on claims configuration updates and changes
· Resolve escalated and complex processing, change requests, issues, or questions
· Manage and maintain benefit documentation for internal & external customers
· Annual review of new CPT & HCPCS code coverage determinations, considering member benefits, medical necessity and industry standard coverage policies
· Responsible for own workflow assignments and must be able to take the initiative to resolve problems and meet deadlines
Minimum Qualifications
· 3-5 years health plan benefit configuration experience
· Certification as a professional coder (CPC) – preferred
· 1+ years medical coding experience with demonstrated sustained coding quality
· Advanced knowledge of CPT/HCPCS/Revenue Code, procedure coding, ICD10 coding, principles and practices
· In-depth knowledge of coding/classification systems appropriate for inpatient, outpatient, HCC, CRG and DRG
· Ability to research authoritative citations related to coding, compliance, and additional reporting needs
· Demonstrates overall knowledge of claims processing for various insurances both private and government
· Excellent computer skills, able to learn, use and toggle between multiple systems
· Analytical skills and ability to create reports, charts and graphs (e.g., Microsoft Excel)
· Ability to work independently or in a team setting, while handling multiple projects and adjusting to changes quickly while meeting all deadlines
Professional Competencies
· Integrity and Trust
· Customer Focus
· Functional/Technical skills
· Written/Oral Communication
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Configuration Coder • New York City, NY
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