1199seiu - New York, NY

posted 4 months ago

Full-time
New York, NY

About the position

The Healthcare Claims Coding Analyst position is a critical role within the Benefits Administration department, located in New York, NY. This full-time, permanent position is responsible for ensuring accurate coding and compliance in healthcare claims processing. The analyst will conduct annual and quarterly reviews of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, ensuring that coding logic aligns with Medicare policies and reimbursement determinations made by the Chief Medical Officer. This role requires a comprehensive understanding of coding regulations and the ability to modernize coding reimbursement policies through detailed maintenance reviews of various codes, including Molecular Pathology and proprietary laboratory analyses codes. In addition to reviewing and updating coding policies, the Healthcare Claims Coding Analyst will develop customized claims auditing and clinical coding policies, utilizing statistical data to analyze large claims datasets. This analysis will help identify provider billing patterns and ensure compliance with industry standards. The analyst will also perform complex compliance audits on pended claims, identifying errors and recommending corrective actions for any deficiencies or irregularities found. This involves a thorough understanding of healthcare coding conventions and the ability to interpret Fund contracts and policies. Collaboration with various departments is essential, as the analyst will define policy criteria according to current clinical coding rules and interact with the medical claims processing program's production department for testing purposes. The role also involves maintaining the rules and policies in the Fund's advanced claim auditing software, ensuring that claims are processed efficiently and accurately. The analyst will work closely with management to develop and update operating procedures, monitor compliance, and generate reports that summarize cost savings and track outcomes. Training staff and conducting quality control activities are also key responsibilities of this position. The Healthcare Claims Coding Analyst will design and implement quality improvement initiatives, ensuring that all processes align with documented policies and standards. This role is vital for maintaining the integrity of the Fund's claims processing and ensuring that providers are reimbursed accurately for their services.

Responsibilities

  • Annually and quarterly review and research all new CPT and HCPCS codes for coding logic and related Medicare policies.
  • Perform comprehensive maintenance review on all Fund policies and various coding systems to modernize coding reimbursement policies.
  • Develop enhanced claims auditing and clinical coding policies, monitoring and analyzing outcome results annually.
  • Utilize statistical data to analyze large claims datasets and provide reports on provider billing patterns compared to industry standards.
  • Perform complex compliance claims audits on pended claims, identifying errors and recommending corrective actions.
  • Review and make payment/denial recommendations for claims on the daily Professional Active Codes Without Rate Report.
  • Collaborate with departments to define the Benefit Fund's policy criteria according to clinical coding rules.
  • Maintain rules and policies in the Fund's advanced claim auditing software, ensuring accurate claims processing.
  • Work with management to develop and update operating procedures for data management activities.
  • Craft user manuals and documentation to support clinical compliance initiatives.
  • Train staff as necessary on coding and compliance processes.
  • Design and conduct quality control and improvement activities, tracking results and recommending corrective actions.
  • Perform additional duties and projects as assigned by management.

Requirements

  • Bachelor's degree in health care or related field or equivalent years of work experience required.
  • Minimum five (5) years senior level experience in medical outpatient claims adjudication and clinical coding reviews required.
  • Direct experience with professional/HCFA claims management and coding rules required.
  • AAPC Certified Professional Coder (CPC) or AHIMA Certified Coding Specialist - Physician-Based (CCS-P) credential required.
  • Advanced experience in medical terminology and coding (CPT, HCPCS, Modifiers) required.
  • Advanced skill level in Microsoft Word and Excel required.
  • Intermediate experience with Lyric claims auditing software preferred.
  • Solid aptitude in math with frequent use of calculation functions.

Nice-to-haves

  • AAPC Certified Outpatient Coder (COC) or AHIMA Certified Coding Specialist (CCS) credential is a plus.
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