Claim Edit and Vendor Integrity Specialist, Geisinger Health Plan ( Eastern United States resident )

Job Summary

Our successful candidate has experience collaborating with external vendors in a healthcare claims or payment integrity environment, including implementation support, claim-edit validation, issue escalation and resolution, performance monitoring, and ongoing vendor relationship management.

Job Duties

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.

• Applies expanded knowledge of CPT, ICD-10 and HCPCS coding skills toward 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 of one Certification required:

Certified Professional Coder (CPC) with AAPC

Certified Coding Specialist with AHIMA certifications

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 Coding Specialist - American Health Information Management Association (AHIMA); Certified Professional Coder - American Academy of Professional Coders (AAPC)

OUR PURPOSE & VALUES: Everything we do is about caring 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 We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.

We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.