Job Title
At the direction of the assigned leadership, interprets business rules, federal and state guidelines and prepares specifications for all information systems, including benefiting and pricing requirements for claims processing. Develops and maintains reporting as needed by leadership and operational objectives. Assists in the enforcement of product, reporting and service controls and standards, deadlines, and schedules by creating and maintaining detailed development plans. Defines test scenarios, involved in testing, and approval of testing results for implementation to ensure business requirements are met. Responsible for change management that impact claims configuration for all systems.
Essential Functions and Responsibilities
- Interprets business rules, Federal and State guidelines, including but not limited to outpatient coding to create rules for processing within systems to ensure requirements are met.
- Responsible for auditing medical records against submitted claims to verify accuracy of coding and identify coding errors.
- Analyzes requirements, specifications, business processes, provider contracts and provides recommendations for system configuration.
- Manages and oversees all changes that impact claims configuration to systems, including updating business processes and documentation, education to impacted departments, and coordinating changes.
- Creates detailed development plans to enforce appropriate production, reporting and service control and standards to ensure deadlines are met to meet requirements.
- Maintains a change control database to document all changes implemented including dates, change description, testing, approval and evaluation after the change has been implemented.
- Continually monitors legislation for preventive guidelines and coverage, maps HCPCS, CPT, and ICD-10 coding to coverage guidelines and ensures system updates are timely and accurate to standards and publications.
- Maintains knowledge of current coding guidelines and participates in internal and external quality review meetings, responses, and corrective action development for corporate and outsourced.
- Works collaboratively with appropriate departments such as system configuration, compliance, legal, medical management, etc.
- Other duties as assigned or when necessary to maintain efficient operations of the department and the company as a whole.
This is a 52% markup need. Contractors need to make a facility mandated pay rate of $26.34 per hour.
Requirement Description
- Required: Associate degree in Health Information Management, Applied Science, Business Administration, Health Care Administration or equivalent program with emphasis on coding; or High school diploma with two (2) years of related experience.
- Required: Certified Medical Coder (CPC, RHIT or RHIA).
- Required: Two (2) years' experience and knowledge of HMO, PPO, TPA, PHO and Managed Care functions.
- Required: Two (2) years' experience in analytic role utilizing systems and data.
- Understands this is a temp job only - Required
- 1 year of experience in Claims or Data Entry - Required
- Please verify full home address - Required
Approved to hire in: AL, FL, GA, IN, IA, KY, MI, MO, NC, OH (not Cincinnati or Toledo), SC, TX. All other states are a no hire.
This is a 52% markup need. Contractors need to make a facility mandated pay rate of $26.34 per hour. Other requirements to note while working on this submission:
- Must disclose if your candidate has ever worked at any McLaren site or affiliate.
- Do NOT include any Medical or Personal information that could be construed as a reason not to hire.