at Blue Cross Blue Shield Association in Chicago, Illinois, United States
Job Description
The Medical Coding Program Manager is a medical coding Subject Matter Expert responsible for managing complex, cross-functional projects and making recommendations to align with strategic goals. Responsible for services and related deliverables associated with medical policy, benefit administration, claims editing and other related areas. The Manager leads medical coding functions impacting core claims processing, payment policy and other internal departments as well as interacts with Plans to provide coding education to support local medical policy and internal processes. Ultimately, the role serves as a coding expert, assimilating trends and requested information into sound recommendations resulting in value-added resources for internal staff, Plans, and external customers.
Research, review, and interpret clinical and industry coding literature, applicable federal regulations, contract requirements and standards of clinical practice. Stays abreast of all industry professional and facility code modifications, rules and regulations as released and identifies appropriate claims system classification, benefit assignment, as well as medical and pharmacy policy placement to ensure accurate claims payment and medical review decision making.
Continually reviews clinical validity and compatibility of code placement in claims system edits and policies; identifies creative solutions and promptly initiates process to address issues; recommends changes to appropriate workgroups.
Manages and performs multi-faceted complex projects associated with appropriate medical coding associated with but not limited to data/analytics, claims editing, actuarial assessment, Case, Utilization, and disease management, quality metrics, benefit design and implementation, and medical and pharmacy policies.
Provides education and guidance on medical coding implications to internal and external customers and the Plans; Serves as a Subject Matter Expert, resource and liaison to the Plans ensuring they have accurate interpretation of coding rules and regulations and are correctly administering Benefits in accordance with the Service Benefit Plan, the Office of Personnel Management (OPM), and applicable federal regulations; promptly initiating processes for corrective measures.
Compiles, maintains, and analyzes data and information contained in
current analytical programs, including independent query creation. Produces analytical reports, including executive summary and recommendations. Utilizes complex databases and research methodology for data analysis and trending reports. Ensures data collection, manipulation and maintenance of systems are effective and meets organizational needs. Serves as a liaison or contact between FEP analytics and key customers including the Office of Personnel Management.
Maintains knowledge of current and emerging managed care issues related to medical coding which impact stakeholders; educates Plans on critical information through various communication mediums, providing direction and guidance on operational policy and identifying critical priorities.
Education
Required/Preferred: Bachelors degree in health administration, nursing, or public health
Certifications
Required: Certified by the American Academy of Professional Coders as a Certified Professional Coder
Preferred: Certificate by the Academy of Healthcare Management
Preferred; Active unrestricted license as a Registered Nurse in the United States
Experience
Required:
10 years experience with extensive knowledge of medical coding including CPT, HCPCS, ICD10 CM and PCS code sets and facility based coding. Experience in working with utilization management and audit as well as extracting clinical information from medical policies and assigning appropriate diagnosis and procedure codes.
5 years experience with FEP Claim system editing
5 years experience in data analytics including systems such as Analytics 2.0 abd.ir FIRE
5 years experience in presenting to professional groups
Skills
Graduate degree in health administration, nursing or public health
Degree in Nursing or health related field
Experience in medical coding involving extracting clinical information from medical records and assigning appropriate diagnosis, procedure, modifier, and/or revenue codes
Business experience with a minimum of five years related experience in a similar environment
Experience in data analysis/interpretation, producing reports, and related work
Experience in presenting to professional groups
Software applications experience (e.g., Microsoft Word, Excel, and PowerPoint)
Advanced... For full info follow application link.
Blue Cross Blue Shield Association is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, national origin, age, gender identity, disability, veteran status, genetic information or any other legally protected characteristics.
