Medical Policy & Coding Project Consultant- RN/CRNP
$72,870–$137,290 year
RemoteUnited States
Job Summary
Research, maintain, and identify CPT, CDT, HCPCS, ICD-10, and revenue codes to meet business needs while independently managing episodic and special projects involving clinical research, policy development, and audit recommendations. Draft and revise large medical policies, conduct quarterly and annual code reviews, and propose medical policy adoption to leadership based on external BCBSA MPP meetings and scientific evidence. Collaborate with the Coding Team Lead to provide staff training, lead interdepartmental networking for clinical initiatives, and present data analysis findings to diverse internal and external audiences. Work independently with minimal supervision to handle confidential information in compliance with HIPAA and regulatory standards, utilizing advanced analytical skills to resolve complex business and technical problems.
Required Qualifications
- Current, non-restricted clinical license
- Bachelor's Degree in Nursing
- Minimum of 5 years in a clinical setting, and medical coding position
- Preferred five (5) years' experience of medical coding including: ICD-10, CPT, CDT, HCPCS and revenue codes
- Certification from the American Association of Professional Coders (AAPC) Medical Coding
- Knowledge of the health care industry, including standards, policies, familiarity with clinical and business practices, and procedures for multiple departments/systems, especially those related to claims administration, information services, provider networks, clinical, and SIU
- Understanding of the corresponding business practices and interrelationships with other Plans
- Knowledge of technological applications, terminology and concepts
- Knowledge of web-based technologies (Internet/Intranet), SharePoint, SAS, Microsoft Access, Microsoft Excel, reporting and testing software, as well as other Microsoft Office Suite tools
- Strong working knowledge of benefits, payment policies and claims operating systems
- Strong working knowledge of the principles of both professional and facility payment processes, benefits and claims adjudication processes
- Strong working knowledge of Government regulatory and accrediting requirements (PPACA, FEP, MS, Pennsylvania state regulations, NCQA, URAC, OH and Medical Assistance)
- Advanced understanding of medical terminology
- Basic knowledge of current and emerging treatment modalities with the ability to analyze and interpret medical policy and benefit coverage interrelationships
- Knowledge of IT&D, pre-configuration and configuration and various steps to compose and circulate a medical policy to completion, as needed
- Proficiency in analyzing data and presenting data in an effective manner in order to meet business needs
- Proficiency in data analysis/trending through analyzing claims data related to medical coding
- Ability to interact with a high level of professionalism with all levels of internal/external personnel, including preparing written materials and oral presentations for clinical, technical and non-technical audiences
- Seasoned skills to lead meetings and ensure mutually agreeable solutions among multiple departments, as well as, successful completion of a project
- Demonstrated analytical skills
- Ability to gain knowledge of new clinical and business processes and issues quickly
- Advanced problem-solving and structured analysis/design techniques
- Ability to understand complex interrelated systems and independently resolve business and technical problems encountered
- Ability to adapt to constantly changing priorities
- Ability to work independently with minimal supervision to inspire teamwork among diverse groups
- Project management ability and use of project plans
- Ability to handle information in a confidential manner by adhering to HIPAA and Compliance expectations
- Ability to communicate effectively professionally, respectfully in written and verbal form with both internal and external customers
- Ability to work independently, schedule and manage time effectively
- Ability to adjust to changing job requirements and priorities in order to meet dynamic needs and workflow
- Must occasionally lift and/or move up to 5 pounds
Desired Qualifications
- Advanced Practice Provider degree
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