The Medical Coding Business Analyst provides consultative guidance and analysis related to all aspects of claims procedure coding for the services associated with the CareCentrix portfolio of products. This position will collaborate with cross-functional teams and various internal business partners to proactively identify coding and claim guidance while actively contributing to claim remediation forums.
Primary responsibilities include performing detailed impact and root cause analysis of claims data with a focus on claim billing requirements and associated procedure coding to identify proactive methods to avoid claim rejections or denials while maintaining CCX standard coding artifacts and providing direct support to Product Shared Services team initiatives. Additionally the Medical Coding Business analyst will need to conduct research and surveillance related to industry coding standards published by governing bodies and providing guidance and documentation to CCX business and system initiatives.
• Evaluate, analyze and recommend procedure coding guidance to support claim remediation efforts in cross-functional forums where coding issues are identified.
• Analyze health plan claim denials and rejections and work with claims operations team to identify and remediate situations where CARC/RARC codes are associated with fee schedule or coding errors.
• Quantify trends leveraging claims data which are negatively impacting expected payment or financial performance to lead collaboration and root cause analysis with cross-functional teams to drive improvement.
• Establish standard medical coding guidelines for CareCentrix products defined by industry guidance published by CMS, AMA, or other governing or regulatory organizations, with clear documentation of supporting authority.
• Perform ongoing independent research related to changes in industry standard medical coding and impact analysis with a focus on claims processing, as well as potential internal and external stakeholder process changes which may be required.
• Maintain CCX standard coding artifacts affected by changes implemented by governing bodies, new services to market, product enhancement or tailoring efforts or in support of new product development and develop education and communication materials for cross-functional audiences.
• Evaluate all proposals which include procedure coding and provide a recommendation to align with regulatory/compliance, financial, and claims operational perspectives to support stakeholder requests.
• Establish and maintain cross-functional relationships to address claims coding and associated rule issues facing the organization.
• Must perform other duties as required or assigned.
Up to 5% travel required.
• BA/BS degree preferred.
• Coding certification (CPC-P, CPC-A minimum) preferred or obtained within 12 months of employment for candidate with commensurate experience.
• 4 + years of experience to demonstrate proficiency in medical coding, billing, and claim requirements, including a working knowledge of industry guidelines and resources.
• Required technical skillset: Highly proficient in MS Office suite with advanced Excel proficiency.
• Excellent analytical, problem-solving, and communication skills required. Experience with Claims analytics, root cause and trend analysis.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.