1199SEIU Funds

1199 SEIU Funds.

  • New York City, NY


  • Long-term.

  • Full-time.

Responsibilities

  • Annually and quarterly evaluation and research study, as needed, all brand-new CPT and HCPCS codes for coding reasoning, associated Medicare policies, and rate details to make it possible for the Chief Medical Officer to make protection and repayment decisions
  • Perform thorough upkeep evaluation on all Fund policies, HCPCS codes, Molecular Pathology and Proprietary Laboratory Analyses codes, Vaccine codes, Contraceptives/IUD codes and Radiopharmaceuticals which includes analyzing the codes to improve coding compensation policies inclusive of coding guidelines and coding setup
  • Develop boosted, personalized potential claims auditing and medical coding and repayment policies, and the required coding setup for Change Healthcare/McKesson’s Policy Management Module (PMM). A minimum of each year keep track of, handle, determine, and evaluate and report result results for the PMMs. Establish files as needed
  • Utilize analytical information to analyze big claims information sets to offer analyses and reports on existing service provider billing patterns as compared to market basic coding policies; and make suggestions based upon market basic coding reasoning, company guidelines and Fund policy
  • Perform complex compliance declares audits or scientific evaluations on pended claims to examine, research study, and examine CPT and HCPCS declares information. When suggested, determine mistakes, wasteful/excessive billing practices on a claim, supplier and/or code level. This consists of problem shooting, solving concern( s) and/or advising restorative action for shortages, abnormalities and abnormalities. Needs analysis of market basic healthcare coding conventions and Fund policies
  • Collaborate with various departments to specify the Fund policy (PMM) requirements according to present and basic medical coding rules/logic. Connect with QNXT production department to carry out pre and post screening
  • Use and keep the guidelines and Fund policies in ClaimsXten Select, the Fund’s innovative claim auditing software application. This potential application user interfaces with a claims adjudication system to assist make sure that the Fund’s scientific coding and claim modifying reasoning are precise and constant with market basic guidelines to guarantee that claims are processed effectively, and service providers are repaid precisely. Offer instructions to the setup group for needed brand-new edits and modifications to existing guidelines and PMMs. Evaluate the setups that includes auditing, translating, and reporting the outcomes to identify if the edits are being used properly. This is a synergistic group method with the configuration/production group
  • Work carefully with management to establish handle and upgrade running treatments or other appropriate documents for program particular information management activities; screen functional activities to guarantee compliance with recorded policies, treatments requirements and quality enhancement procedures. Produce prompt reports, examine and sum up expense savings reports, track and pattern results and suggest custom-made options for all scientific compliance efforts
  • Craft user handbooks, policy, treatments, or other essential paperwork to support medical compliance efforts
  • Train personnel as essential
  • Design and carry out quality assurance and enhancement activities (energy of software application applications, report generation, test situation advancement, check report results for quality, declares auditing, and so on), track and patterns outcomes, and suggest restorative action for issues, abnormalities and abnormalities
  • Perform extra responsibilities and jobs as appointed by management

Qualifications

  • Minimum 5 (5) years senior level, progressive experience in medical outpatient declares adjudication, scientific coding evaluations for claims, settlement, declares auditing and/or usage evaluation needed
  • Direct and pertinent experience with HCFA claims management, coding guidelines and standards, and evaluating/analyzing claim result results for precise market basic coding reasoning and policies (i.e. CCI, MUE, modifier to treatment recognition, and other CMS and AMA standards, and so on)
  • AAPC accreditation in expert medical coding needed
  • Advanced ability level in Microsoft Word and Excel needed
  • Intermediate level experience with Change Healthcare/McKesson declares auditing software application chosen
  • Solid ability in mathematics with regular usage of computation functions

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1199 SEIU Funds.

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