Healthcare Coding and Managed Care Specialist
2 weeks ago
Job Type
Full-time
Position Overview
The Healthcare Coding and Managed Care Specialist is tasked with the critical responsibility of securing preauthorization for various medical services, including inpatient admissions, outpatient procedures, and advanced imaging. This role involves diligent follow-up on insurance claims, particularly those related to coding denials, and the identification of potential revenue enhancements through reimbursement analysis and audits. The specialist will engage with MedPro Representatives to address carrier-related issues and respond to inquiries from patients, Practice Managers, and medical teams, while also executing additional duties as assigned by the direct supervisor.
Key Responsibilities
- Utilizes the Managed Care Work list to monitor the status of requests, ensuring timely authorizations are obtained at least one week prior to scheduled services whenever feasible.
- Reviews Eligibility and Authorization reports specific to the Diagnostic Center.
- Analyzes data from the Managed Care Work list to propose process enhancements.
- Conducts coding tasks with minimal oversight, demonstrating the ability to manage time effectively while producing high-quality work.
- Addresses coding-related claim denials by evaluating source documentation to determine accurate coding, including CPT, ICD-9-CM, ICD-10-CM, and/or CPT/HCPCS codes and modifiers. Adjusts codes as necessary and provides recommendations in claim notes regarding the re-filing or adjustment of claims, while tracking activities to identify trends.
- Daily reviews and resolves coding edits for Diagnostic Center ALI and Context claims.
- Handles Denial Reports for the Diagnostic Center.
- Uploads files into the electronic medical record system on a daily basis.
- Updates patient accounts with accurate insurance information.
- Proactively assesses carrier trends and communicates findings to relevant personnel.
- Facilitates effective communication among stakeholders involved in coding matters to achieve timely resolutions.
- Stays current with insurance requirements and industry developments related to coding.
- Engages in ongoing coding education through seminars, online training, and industry publications.
- Responds professionally to inquiries from patients and medical staff regarding insurance or account activities.
- Completes assigned reports and projects within established deadlines.
- Maintains positive and collaborative relationships with both internal and external clients.
- Communicates professionally with medical office staff and colleagues.
- Remains informed about current insurance carrier requirements for service pre-authorization.
- Ensures that backup personnel are adequately trained to handle relevant reports during absences.
- Acts as a Patient Service Representative in the absence of designated personnel.
- Performs additional duties as assigned by management.
Corporate Culture Responsibilities
- Adhere to established corporate and departmental policies and procedures.
- Participate in all required corporate and departmental training sessions.
- Uphold the organization's Purpose, Values, and Vision.
- Comply with Corporate Culture Responsibilities.
- Carry out other assigned duties with a positive attitude.
Qualifications
- High school diploma or GED is the minimum educational requirement.
- Certification as a Certified Professional Coder or Certified Coding Associate is required.
- A minimum of two years of experience in the healthcare insurance sector is preferred.
Skills and Abilities
- Exhibit strong customer service skills, excellent interpersonal abilities, and meticulous attention to detail.
- Demonstrate integrity and a commitment to positively impacting patients and colleagues.
- Collaborate effectively with team members across all organizational levels.
- Adapt to frequent changes and manage time effectively to fulfill job responsibilities.
- Proficient in relevant software applications, including PPP, Horizon System, Microsoft Excel, and Word.
- Possess strong written and verbal communication skills in English.
- Ability to engage with individuals from diverse socio-economic backgrounds.
- Display active listening skills and maintain professionalism in all interactions.
- Commitment to safeguarding confidential information and records.
- Maintain focus and productivity in a shared work environment.
Physical and Emotional Requirements
- Ability to exert up to 10 pounds of force occasionally.
- Occasional standing and walking required.
- Frequent keyboarding and dexterity needed.
- Capability to focus on a computer screen for extended periods.
- Ability to perform repetitive hand and finger motions.
- Flexibility to work in various positions for extended durations.
- Effective verbal communication skills are essential.
- Must possess good hearing and vision.
Work Environment
- Frequent interruptions may occur during daily tasks.
- Availability to assist customers and staff throughout the day is required.
- Extended hours may be necessary to meet departmental needs.
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