Commonwealth Care Alliance
Medicare/Medicaid Claims Editing Specialist
Commonwealth Care Alliance, Boston, Massachusetts, us, 02298
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Medicare/Medicaid Claims Editing Specialist
role at
Commonwealth Care Alliance This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this time. Position Summary
Working under the direction of the Sr. Director, TPA Management and Claims Compliance, Healthcare Medical Claims Coding Sr. Analyst will be responsible for developing prospective claims auditing and clinical coding and reimbursement edits and necessary coding configuration requirements for Optum CES and Zelis edits. This role will ensure that the applicable edits are compliant with applicable Medicare and Massachusetts Medicaid regulations. Supervision Exercised
No, this position does not have direct reports. Essential Duties & Responsibilities
Develop enhanced, customized prospective claims auditing and clinical coding and reimbursement policies and necessary coding configuration requirements for Optum CES and Zelis edits. Quarterly and Annual review and research, as necessary on all new CPT and HCPCS codes for coding logic, related Medicare/Medicaid policies to make recommend reimbursement determinations. Analyze, measure, manage, and report outcome results on edits implemented. Utilize data to examine large claims data sets to provide analysis and reports on existing provider billing patterns as compared to industry standard coding regulations, and make recommendations based on new/revised coding edits for presentation to Payment Integrity committee meetings. Analyze, measure, manage, and report outcome results on edits implemented. Use and maintain the rules and policies specific to CES and Zelis. Query and analyze claims to address any negative editing impacts and create new opportunities for savings based on provider billing trends Liaison between business partners and vendors; bringing and interpreting business requests, providing solutioning options and documentation, developing new policies based on State and Federal requirements, host meetings, and managing projects to completion Define business requests received, narrow the scope of the request based on business needs and requirements, provider resolution option based on financial ability and forecasting for small to large Operations Management Collaborate system and data configuration into CES (Claims Editing System) with BPaaS vendor and other PI partners, perform user acceptance testing, and analyze post production reports for issues Support collaboration between PI/Claims and other internal stakeholders related to the identification and implementation of cost-savings initiatives specific to edits. Working Conditions
Standard office conditions. Remote opportunity. Requirements
Bachelor’s Degree or Equivalent experience 7+ years of Healthcare experience, specific to Medicare and Medicaid 7+ years progressive experience in medical claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required 7+ years experience with Optum Claims Editing System (CES), Zelis, Lyric or other editing tools Extensive knowledge and experience in Healthcare Revenue Integrity, Payment Integrity, and Analytics Knowledge and experience of claim operations, health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare) Medical Coding, Compliance, Payment Integrity and Analytics
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Medicare/Medicaid Claims Editing Specialist
role at
Commonwealth Care Alliance This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this time. Position Summary
Working under the direction of the Sr. Director, TPA Management and Claims Compliance, Healthcare Medical Claims Coding Sr. Analyst will be responsible for developing prospective claims auditing and clinical coding and reimbursement edits and necessary coding configuration requirements for Optum CES and Zelis edits. This role will ensure that the applicable edits are compliant with applicable Medicare and Massachusetts Medicaid regulations. Supervision Exercised
No, this position does not have direct reports. Essential Duties & Responsibilities
Develop enhanced, customized prospective claims auditing and clinical coding and reimbursement policies and necessary coding configuration requirements for Optum CES and Zelis edits. Quarterly and Annual review and research, as necessary on all new CPT and HCPCS codes for coding logic, related Medicare/Medicaid policies to make recommend reimbursement determinations. Analyze, measure, manage, and report outcome results on edits implemented. Utilize data to examine large claims data sets to provide analysis and reports on existing provider billing patterns as compared to industry standard coding regulations, and make recommendations based on new/revised coding edits for presentation to Payment Integrity committee meetings. Analyze, measure, manage, and report outcome results on edits implemented. Use and maintain the rules and policies specific to CES and Zelis. Query and analyze claims to address any negative editing impacts and create new opportunities for savings based on provider billing trends Liaison between business partners and vendors; bringing and interpreting business requests, providing solutioning options and documentation, developing new policies based on State and Federal requirements, host meetings, and managing projects to completion Define business requests received, narrow the scope of the request based on business needs and requirements, provider resolution option based on financial ability and forecasting for small to large Operations Management Collaborate system and data configuration into CES (Claims Editing System) with BPaaS vendor and other PI partners, perform user acceptance testing, and analyze post production reports for issues Support collaboration between PI/Claims and other internal stakeholders related to the identification and implementation of cost-savings initiatives specific to edits. Working Conditions
Standard office conditions. Remote opportunity. Requirements
Bachelor’s Degree or Equivalent experience 7+ years of Healthcare experience, specific to Medicare and Medicaid 7+ years progressive experience in medical claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required 7+ years experience with Optum Claims Editing System (CES), Zelis, Lyric or other editing tools Extensive knowledge and experience in Healthcare Revenue Integrity, Payment Integrity, and Analytics Knowledge and experience of claim operations, health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare) Medical Coding, Compliance, Payment Integrity and Analytics
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