Coding and Cost Analyst I – Medical Claims Coding, Claim Edit Review

Job Description: • Contributes to the achievement of the strategic and financial goals of the organization by conducting thorough reviews of billed services, authorizations, plan benefit documents, itemized statements, medical records, discharge summaries and detailed data reports. • Makes reimbursement or recovery recommendations based on appropriate coding, billed statistics, policies, industry standards and compliance with contractual, state, and federal regulations. • Supports and serves as a resource to other Health Plan departments by providing review and recommendation for correct coding, appropriate billing, and reimbursement. • Completes clinical reviews related to Claims, Claim Edits, Appeals and the Grievance process, assisting in analysis of clinical risk related to Underwriting, Pharmacy, and Finance departments. • Recommends recovery efforts based on current contracts, policies, procedures and accepted industry standards. • Reviews and validates pended and reconsidered claims when edits are applied by the Plan claim editing software from multiple vendors. • Completes reviews on inpatient and outpatient high dollar claims following internal guidelines. • Assists in reviews of quality concerns. • Validates claim payments based on Plan contracts, often working with the Pharmacy team and the PNM department. • Creates and maintains various reports to track department data. • Assists in group discussions on challenging medical reviews. • Assists with onboarding new team members as needed. • Participates on selected workgroups and committees on an ad hoc basis as requested. Requirements: • Minimum of 1 certification required: CPC-Certified Professional Coder through AAPC CCS- Certified Coding Specialist through AHIMA LPN preferred. • High School Diploma or Equivalent (GED) - (Required). • Minimum of 3 years-Relevant experience* (Required). • Minimum of 2 years-Clinical (Preferred). Benefits: • healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. • atmosphere of collaboration, cooperation and collegiality. • diverse workforce with unique experiences and backgrounds makes our team stronger. • affirmative action, equal opportunity employer. Apply tot his job