Clinical Certified Professional Coder - Horizon Blue Cross Blue Shield of New Jersey
This position is accountable for the review, interpretation and codification of Medical Policies and Legislative Mandates utilizing CPT-4, HCPC and ICD-9/ICD-10 coding parameters.
Reviews and interprets current Medical Policies for systematization.
Translates written policy into CPT, HCPC, ICD-9/ICD-10 codes for input into systems.
Translates Legislative Mandates into CPT, HCPC, ICD-9/ICD-10 codes for input into systems.
Monitors State and CMS coding and coverage notifications and ensure internal tools, resources, systems and users are notified. Follow through and ensure all necessary changes are completed.
Using clinical skills, experiences and expertise identifies and determines appropriateness, inclusion and relevance of services and their codes as they pertain to a medical or payment policy and or initiative.
Performs functions to ensure integrity of resources and tools used by the Enterprise, for code set management, policies, mandates, clinical editing rules and benefit coding are maintained.
Monitor compliance of code use with policies and procedures relevant to clinical data and claim audits.
Apply knowledge of industry standard and established rules, regulations and guidelines of coding and billing practices for both professional and facility claims to respond to cross-departmental and LOB inquiries and needs. -Review, analyze, and audit claims across LOB to identify inappropriate billing practices, and or system configuration issues and follow through as needed to ensure changes are completed.
Prepare reports, charts and summaries for project presentation to internal stakeholders when applicable.
Provide expertise and guidance on proper billing and coding practices as they relate to benefit development, quality initiatives and application of specialized programs across the Enterprise.
Participate in new program initiatives, providing code identification, configuration parameters, BRD/TRD development, testing, and when applicable assist with drafting of payment policies.
Assist with the annual review of payment policies for Medicare and Medicaid LOB making changes as required with industry and coding changes.
Perform other related tasks as assigned.
Requires proficiency in the CPT-4, HCPC, ICD-9/ICD-10 coding
Requires experience with physician and facility coding and billing of services
Requires knowledge of anatomy, physiology and medical terminology of medical procedures, abbreviations and terms
Requires knowledge of the health care delivery system
Prefer knowledge of state and federal laws and regulations, including CMS, DOBI and DMAHS requirements
Skills and Abilities:
Requires the ability to utilize a personal computer and applicable software ( e.g. proficiency in Word, Excel, Access).
Requires executive function and logic skills to troubleshoot configuration issues.
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
Demonstrated Excel conditional formatting, function usage, charting, Pivot tables and reporting skills.
Must demonstrate professional and ethical business practices, adherence to company standards and a commitment to personal and professional development Proven ability to exercise sound judgment and strong problem solving skills.
Proven ability to ask probing questions and obtain thorough and relevant information.
Must have the ability to organize/prioritize/analyze complex tasks.
Experience using CMS website for correct coding, billing manuals, NCD/LCD, articles and bulletins
Experience using New Jersey Medicaid website for billing, policies, bulletins and contract applicability.
Requires Bachelor's degree from an accredited college or university. Clinical medical background (RN, Foreign-trained medical school graduate) required.
Requires 3 - 5 years of Medical Coding experience.
Requires a minimum of 2 years' experience in Health Insurance/Claims Processing and/or Utilization Review.
Prefer knowledge/experience with computer processing systems and databases.
Additional licensing, certifications, registrations:
Requires Licensed Registered Nurse or Foreign-trained medical school graduate.
Requires current Registered Health Information Technologies (RHIT) or Certified Professional Coder designation from the American Academy of Professional Coders or a Certified Coding Specialist, P from the American Health Information Management (AHIMA).