CareFirst, Inc.
Senior Medical Coding Specialist (Remote)
CareFirst, Inc., Baltimore, Maryland, United States, 21276
RESP & QUALIFICATIONS
Purpose: Acts as an internal expert to ensure that value‑based reimbursement and medical policy models are developed and implemented. Provides expert knowledge to support effective partnership with provider entities and guidance on the appropriate quality measure capture and proper use of CPT, HCPCS, and ICD 10 codes in claims submissions.
ESSENTIAL FUNCTIONS
Consults on proper coding rules in value‑based contracts to ensure appropriate quality measure capture and proper use of CPT, HCPCS, and ICD 10 codes. Provides expertise on the financial and incentive impacts and strategizes solutions to maximize quality payments and risk adjustment.
Serves as a technical resource and coding subject‑matter expert for contract pricing issues. Conducts complex analyses to assure payments are compliant and identifies improvement opportunities for operational efficiency. Provides problem‑solving expertise on systems issues when a code is not accepted and troubleshoots complex coding and billing issues.
Develops and refines effective guides and resources for providers on expected billing and code‑submission methodologies to maximize quality and STAR outcomes while maintaining payment integrity. Interfaces directly with provider groups during proactive training events or for complex claim matters.
Participates in strategy and contributes to thought leadership for quality measure capture (NCQA, HEDIS, STARs). Collaborates with internal stakeholders on process and outcome improvement activities and ensures compliance with all coding standards.
Facilitates mentorship, providing assistance to less seasoned team members.
Actively researches industry trends, keeping up‑to‑date and maintaining a high level of coding expertise.
SUPERVISORY RESPONSIBILITY Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
QUALIFICATIONS Education Level: High School Diploma or GED.
Experience: 5 years in risk adjustment coding, ambulatory coding and/or CRC coding experience in managed care; state or federal health care programs; or health insurance industry experience.
PREFERRED QUALIFICATIONS
Bachelor's degree in a related discipline
Certified public accountant
Experience in medical auditing
Experience in training, education, and presenting to large groups
KNOWLEDGE, SKILLS AND ABILITIES (KSAs)
Knowledge of billing practices for hospitals, physicians and/or ancillary providers as well as knowledge about contracting and claims processing.
Experience in revenue cycle management and value‑based reimbursement/contracting models and methodologies.
Detail‑oriented with an ability to manage multiple projects simultaneously.
Excellent communication skills both written and verbal.
Demonstrated ability to effectively analyze and present data.
Ability to create educational materials, training manuals, and/or procedural guides.
Experience in using Microsoft Office (Excel, Word, PowerPoint, etc.) and a demonstrated ability to learn/adapt to computer‑based tracking and data collection tools.
LICENSES / CERTIFICATIONS ON HIRE REQUIRED
CCS‑Certified Coding Specialist
Certified Coder (CCS or CPC) – AHIMA or AAPC
SALARY RANGE $65,880 – $130,845.
EEO STATEMENT CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
#J-18808-Ljbffr
ESSENTIAL FUNCTIONS
Consults on proper coding rules in value‑based contracts to ensure appropriate quality measure capture and proper use of CPT, HCPCS, and ICD 10 codes. Provides expertise on the financial and incentive impacts and strategizes solutions to maximize quality payments and risk adjustment.
Serves as a technical resource and coding subject‑matter expert for contract pricing issues. Conducts complex analyses to assure payments are compliant and identifies improvement opportunities for operational efficiency. Provides problem‑solving expertise on systems issues when a code is not accepted and troubleshoots complex coding and billing issues.
Develops and refines effective guides and resources for providers on expected billing and code‑submission methodologies to maximize quality and STAR outcomes while maintaining payment integrity. Interfaces directly with provider groups during proactive training events or for complex claim matters.
Participates in strategy and contributes to thought leadership for quality measure capture (NCQA, HEDIS, STARs). Collaborates with internal stakeholders on process and outcome improvement activities and ensures compliance with all coding standards.
Facilitates mentorship, providing assistance to less seasoned team members.
Actively researches industry trends, keeping up‑to‑date and maintaining a high level of coding expertise.
SUPERVISORY RESPONSIBILITY Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
QUALIFICATIONS Education Level: High School Diploma or GED.
Experience: 5 years in risk adjustment coding, ambulatory coding and/or CRC coding experience in managed care; state or federal health care programs; or health insurance industry experience.
PREFERRED QUALIFICATIONS
Bachelor's degree in a related discipline
Certified public accountant
Experience in medical auditing
Experience in training, education, and presenting to large groups
KNOWLEDGE, SKILLS AND ABILITIES (KSAs)
Knowledge of billing practices for hospitals, physicians and/or ancillary providers as well as knowledge about contracting and claims processing.
Experience in revenue cycle management and value‑based reimbursement/contracting models and methodologies.
Detail‑oriented with an ability to manage multiple projects simultaneously.
Excellent communication skills both written and verbal.
Demonstrated ability to effectively analyze and present data.
Ability to create educational materials, training manuals, and/or procedural guides.
Experience in using Microsoft Office (Excel, Word, PowerPoint, etc.) and a demonstrated ability to learn/adapt to computer‑based tracking and data collection tools.
LICENSES / CERTIFICATIONS ON HIRE REQUIRED
CCS‑Certified Coding Specialist
Certified Coder (CCS or CPC) – AHIMA or AAPC
SALARY RANGE $65,880 – $130,845.
EEO STATEMENT CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
#J-18808-Ljbffr