Coding and Cost Analyst I - medical claims coding and edit review, Geisinger Health Plan (Pennsylvania resident)

• Supports and serves as a resource to other Health Plan departments by providing review and recommendation for correct coding, appropriate billing, and reimbursement.
• Completes clinical reviews related to Claims, Claim Edits, Appeals and the Grievance process, assisting in analysis of clinical risk related to Underwriting, Pharmacy, and Finance departments.
• Recommends recovery efforts based on current contracts, policies, procedures and accepted industry standards.
• Reviews and validates pended and reconsidered claims when edits are applied by the Plan claim editing software from multiple vendors. Reviews are typically based on CPT guidelines, industry standards and CMS guidelines.
• Completes reviews on inpatient and outpatient high dollar claims following internal guidelines. Assists in reviews of quality concerns.
• Validates claim payments based on Plan contracts, often working with the Pharmacy team and the PNM department.
• Creates and maintains various reports to track department data.
• Assists in group discussions on challenging medical reviews.
• Assists with onboarding new team members as needed.
• Participates on selected workgroups and committees on an ad hoc basis as requested.

Work is typically performed in a work-from-home office which must be secure and follow HIPAA Privacy standards. 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. Attend occasional onsite department meetings as needed.

#LI-REMOTE

Minimum ONE Certification required:
CPC-Certified Professional Coder through AAPC

CCS- Certified Coding Specialist through AHIMA

LPN preferred.

*Relevant experience may be a combination of related work experience and/or completed specialty training program (1 year of specialty training = 1 year relevant experience).