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Resp & Qualifications

PURPOSE:

Acts as an internal expert to ensure that as 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. Utilizes coding expertise, combined with medical policy, credentialing, and contracting rules knowledge to build the effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity. This role ensures accurate interpretation, application, and integration of medical codes across policies and platforms. The Senior Coding Analyst partners with medical policy analysts, configuration teams, and payment integrity staff to support the accurate, timely, and compliant administration of benefits. Provides expertise and mentoring to other team members.

ESSENTIAL FUNCTIONS:

+ Consults on proper coding rules in value-based contracts to ensure appropriate quality measure capture and proper use of CPT, HCPCS, and ICD10 codes. Provides expertise on various consequences for different financial and incentive models. Strategizes alternatives and solutions to maximize quality payments and risk adjustment. Translates from claim language to services in an episode or capitated payment to articulate inclusions and exclusions in models.

+ Serves as a technical resource / coding subject matter expert for contract pricing related issues. Conducts complex business and operational analyses to assure payments are in compliance with contract; identifies areas for improvement and clarification for better operational efficiency. Provides problem solving expertise on systems issues if a code is not accepted. Troubleshoots, make recommendations and answer questions on more complex coding and billing issues whether systemic or one-off.

+ Develops and refines effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity. May interface directly with provider groups during proactive training events or just in time on complex claims matters. Consults with various teams, including the Practice Transformation Consultants, Medical Policy Analysts and Provider Networks colleagues to interpret coding and documentation language and respond to inquiries from providers.

+ 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. Ensure 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 expertise in coding rules and standards.

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 experience 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 related discipline

+ Certified public accountant

+ Experience in medical auditing

+ Experience in training/education/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, Power Point, etc.) and demonstrated ability to learn/adapt to computer-based tracking and data collection tools.

Licenses/Certifications Upon Hire Required:

+ CCS-Certified Coding Specialist

+ Certified Coder (CCS or CPC)-AHIMA or AAPC

Salary Range: $65,880 - $130,845

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Medical Policy

Equal Employment Opportunity

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.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.

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REQNUMBER: 21330