Claims Coding Analyst

The Claims Coding Analyst's primary responsibilities require independent judgement in making coding-based decisions on claims and appeals to maintain and enhance Healthfirst's claims editing systems in ensuring proper claims payments, reviewing, researching, and responding to written and emailed correspondence from providers regarding claim denials, and acting as a subject matter expert handling more complex provider issues. They are involved in setting Healthfirst claims policy and ensure that Healthfirst payment policy is aligned with CMS (Centers for Medicare and Medicaid Services), New York State Department of Health (NYSDOH), and all CPT, HCPCS, and ICD-10 coding guidelines, among others. Work Schedule This position requires three days per week in office (Tues/Wed/Thurs) at either: 1101 Greenwood Blvd. Lake Mary, FL. or 100 Church St. New York, NY. Duties & Responsibilities : Conducts independent assessments of current claims edits to ensure comprehensive and defensible claims editing is in place across all Healthfirst product lines. Proactively identifies areas of opportunity with respect to new edits, modifications to existing edits, and recommended claims policy changes. Leads implementation efforts with respect to new or modified edits and works with other departments to ensure proper integration with existing systems and edits. Monitors and reports on performance of current claims editing packages to substantiate savings to Healthfirst. Serves as a subject matter expert to defend claims payment policy disputes and appeals. Reviews claims editing escalated provider disputes/appeals and provides guidance on coding rules and industry standards across all areas of the company with regards to claims editing and proper coding, billing, and payment. Researches and provides feedback on claims editing performance issues, both internally and externally with providers, vendors, etc. Collaborates with claims editing vendors to maintain and update edits as changes in the regulatory, legislative, or industry accepted payment policy requires. Collaborates with other departments to improve compliance with coding conventions and clinical practice guidelines. Leads continuous improvement and quality initiatives to improve processes across departments. Reviews and responds to written provider disputes, clearly and articulately outlining the payment discrepancy to the provider. Thoroughly researches post payment claims and takes appropriate action to resolve identified issues within turnaround time requirements and quality standards. Navigates CMS and State specific websites, as well as AMA guidelines, and compares to current payment policy configuration to resolve the provider payment discrepancies. Reviews medical records to ensure coding is consistent with the services billed and compares against the clinical coding guidelines to determine if a claim adjustment is necessary. Processes claim adjustment requests following all established adjustment and claim processing guidelines. Identifies and escalates root cause issues to supervisor for escalated review. Reviews and responds independently to internally escalated provider disputes transferred by management and other associates. Additional duties as assigned Minimum Qualifications: Coding certification from either American Academy of Professional Coders (AAPC), Certified Professional Coders (CPC) or American Health Information Management Association (AHIMA). High school diploma or GED from an accredited institution. Preferred Qualifications: Previous relevant experience Bachelor's degree in related field Time management, critical/creative thinking, communication, and problem-solving skills Demonstrated professional writing, electronic documentation, and assessment skills. Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills. Knowledge of anatomy and pathophysiology medical terminologies. Compliance & Regulatory Responsibilities: See Above License/Certification: See Above WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid "@healthfirst.org" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $68,900 - $99,620 All Other Locations (within approved locations): $61,300 - $91,120 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.