United States onlyJob Summary:
This is an intermediate-level technical position in the pre-payment high risk claims function intended to analyze claim over and under payments in support of the business units objective to ensure all claims are paid accurately prior to payment and to help control medical cost spend. This role requires a coding certification to independently perform reviews of high risk and/or high dollar claims from a medical coding and provider billing perspective to ensure claims payment integrity. This may include reviews of corresponding medical records to validate billing appropriateness. In addition the role is responsible for ensuring claims are paid according to the provider and member contracts as well as ensuring that standard claims processing guidelines and billing procedures for each type of service and type of provider were followed. Additionally this role may on occasion interact directly with providers to make final determinations and respond to inquiries as needed.
Essential Functions:
- Independently perform analysis of high risk and/or high dollar claims on a pre-payment basis utilizing coding and claims processing background to ensure claims are neither over nor underpaid.
- Leverage coding background to asses high risk claims for inappropriate application of associated Florida Blue policies and industry standard billing and care practices that may impact claims payment (e.g. MCG, LCD, Authorizations, Covered Benefits, Appropriateness of Service Setting). Specifically:
- Request and independently review pertinent medical documentation to validate/invalidate potential issues identified on high risk/complex claims
- Determine claim level financial impact based on unique member benefits and provider contract terms, rates and payment policies.
- Ensure claims processing compliance with overarching administrative regulations (Federal, State of Florida, BCBS Association etc.).
- Perform claims level analysis of appropriate provider coding and billing practices and/or guidelines
- Coordinate and communicate directly with provider personnel as necessary to understand and communicate identified billing issues.
- Thoroughly document identified issues to support claim adjustments (including supporting medical documentation or coding rationale).
- Participate in special projects, as needed, to support changes in the supporting processes or policies that will impact the pre-payment, claims or care processes.
- Identify and document upstream process gaps driving incorrect payment for remediation and prevention
What is needed in this role:
- 4+ years’ experience in medical billing and coding
- Must have Certified Professional Coding (CPC) certification
- In-depth knowledge of medical terminology and ICD-10, CPT, and HCPCS coding systems
- Strong knowledge of Evaluation and Management (E&M) Coding guidelines
- Strong focus on attention to detail
- Excellent written and verbal skills are required
- Familiarity with encoder systems and electronic medical record (EMR) software
- Bachelors Degree or equivalent experience
What we prefer:
- Strong analytics experience Consulting experience Ability to read and interpret medical records Clinical experience
Experience in a medical office or health care background - Payment integrity review experience is strongly preferred
- Knowledge of Florida Blue payment policies
- Knowledge of Florida Blue systems; Diamond, EWOC, Content Central, Request Central and Prepay UI
General Physical Demands:
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.
To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
- Medical, dental, vision, life and global travel health insurance;
- Income protection benefits: life insurance, short- and long-term disability programs;
- Leave programs to support personal circumstances;
- Retirement Savings Plan including employer match;
- Paid time off, volunteer time off, 10 holidays and 2 well-being days;
- Additional voluntary benefits available; and
- A comprehensive wellness program
Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.
To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.
Annualized Salary Range: $63,800 - $103,600
Typical Annualized Hiring Range: $63,800 - $79,700
Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.
We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.
