Wellmark, Inc.
Insurance
HealthServicesCodingAnalyst(CPCRequired)
Neural analysis suggests this role is
optimal for mid candidates.
“Health Services Coding Analyst (CPC Required) at Wellmark, Inc.. Skills: Medical policy, Claims processing, Medical coding, PGE rules. Provide clinical leadership. Provide subject-matter expertise”
What You'll Achieve.
Assure compliance with medical policy coding requirements; Ensure accurate claims adjudication; Achieve corporate objectives; Achieve UM Product Team objectives; Support managing medical benefit expense; Comply with regulatory standards; Comply with accreditation standards; Comply with internal standards
Industry & Context.
Research system issues; Analyze system issues; Research business issues; Analyze business issues; Resolve coding-related denials; Resolve coding-related overrides; Resolve policy interpretation questions; Resolve complex claims issues; Resolve customer issues; Resolve provider issues; Identify system configuration issues; Resolve system configuration issues
Core business hours 8 AM - 5 PM CT, Provide high-speed internet
What They're Looking For.
Must Have
Associate degree or applicable work experience, Certified Professional Coder (CPC), Clinical background or healthcare experience, 7+ years healthcare experience, Expertise in medical coding, Attention to detail, Ability to multitask, Interpersonal skills, Clear written communication, Concise verbal communication, Inquisitive nature, Workflow management skills, Sense of ownership, Drive and initiative, Ability to communicate concepts clearly, Ability to communicate concepts concisely, Motivate others to achieve success, Promote collegiality, Promote excellence, Obtain relevant information, Relate data from different sources, Compare data from different sources, Proficiency in Microsoft Office, Experience with spreadsheets, Experience with process mapping, Experience with presentation software, Experience with word processing, Adhere to quality metrics, Adhere to production metrics, Meet department work schedule, Coaching and mentoring experience, Consistent department work schedule
Nice to Have
Prior health plan experience, Candidates located in Iowa or South Dakota
What You'll Do.
Provide clinical leadership
Provide subject-matter expertise
Support analysis of medical policy content
Support configuration of medical policy content
Support administration of medical policy content
Maintain claims processing systems
Ensure accurate implementation of medical policies
Ensure accurate implementation of review criteria
Ensure accurate implementation of authorization requirements
Maintain integrity of system infrastructure
Serve as liaison between business and technical teams
Research system issues
Analyze system issues
Research business issues
Analyze business issues
Develop high-level requirements
Serve as expert resource
Mentor Coding Specialists
Train Coding Specialists
Provide policy-related training
Provide policy-related support
Lead analysis of complex medical policy content
Implement system edits
Assure compliance with medical policy coding requirements
Test medical policy coding requirements
Document medical policy coding requirements
Audit medical policy coding requirements
Maintain claims processing system infrastructure
Ensure compliance with regulatory bodies
Ensure compliance with accreditation bodies
Ensure compliance with vendor technical requirements
Ensure accurate claims adjudication
Translate medical policy language
Develop actionable coding criteria
Integrate coding criteria into claims systems
Integrate coding criteria into configuration platforms
Serve as coding subject matter expert
Resolve utilization management issues
Collaborate with Utilization Management nurses
Collaborate with medical directors
Collaborate with claims teams
Resolve coding-related denials
Resolve coding-related overrides
Resolve policy interpretation questions
Contribute to medical policy lifecycle
Draft coding sections
Research emerging procedures
Research emerging devices
Ensure policies reflect current coding conventions
Conduct impact analyses
Provide medical coding expertise
Provide PGE rule knowledge
Resolve complex claims issues
Resolve customer issues
Resolve provider issues
Maintain coding integrity
Monitor utilization trends
Identify system configuration issues
Resolve system configuration issues
Develop coding configuration standards
Optimize coding configuration standards
Develop coding configuration best practices
Optimize coding configuration best practices
Implement Optum edits
Develop Cotiviti edits
Implement Cotiviti edits
Develop Cognizant edits
Implement Cognizant edits
Serve as primary points of contact
Provide expertise to claims processing systems
Support table maintenance
Support FEP guidelines
Support Blue Card guidelines
Support internal processes
Participate in cross functional meetings
Participate in initiatives
Support managing medical benefit expense
Provide expertise in medical coding PGE rule knowledge
Provide expertise in medical policy configuration rules
Support organization initiatives
Consult with leadership
Retain documentation of decisions
Archive documentation of decisions
Comply with regulatory standards
Comply with accreditation standards
Comply with internal standards
Remain current with standards
Remain consistent with standards
Train Coding Specialists
Provide specific topic training
Perform other duties as assigned
How You'll Work.
Team & Collaboration
Business and technical teams; Utilization Management nurses; Medical directors; Claims teams; Health Services leadership; Medical Review staff; Claims leadership; Customer Services leadership; Provider Services leadership; Network Engagement leadership; Medical Directors; Business support teams; Data analytics teams; UM Product Team; Cross functional meetings
Communication Scope
Written communication; Verbal communication; Policy interpretation; Concept communication
Full Job Description
Why Wellmark : We are a mutual insurance company owned by our policy holders across Iowa and South Dakota, and we’ve built our reputation on over 80 years’ worth of trust. We are not motivated by profits. We are motivated by the well-being of our friends, family, and neighbors–our members. If you’re passionate about joining an organization working hard to put its members first, to provide best-in-class service, and one that is committed to sustainability and innovation, consider applying today! Learn more about our unique benefit offerings [here](https://www.wellmark.com/about/careers/benefits). As a Health Services Coding Analyst, you will provide clinical leadership and subject-matter expertise to support the analysis, configuration, and administration of complex medical policy content within claims processing systems, including Plan General Exclusion (PGE) rules and FACETS table maintenance. You will ensure the accurate implementation of medical policies, review criteria, and authorization requirements, while maintaining the integrity of system infrastructure and serving as a key liaison between business and technical teams. To do this, you will research and analyze system and business issues, develop high-level requirements, test and implementsolutions, and audit and document outcomes. The Health Services Coding Analyst also serves as an expert resource for medical policy configuration and PGE coding, mentoring and training Coding Specialists, and providing policy-related training and support to operational partners such as customer and provider services. Must be willing to work core business hours of 8 AM - 5 PM Central Time. Candidates located in Iowa or South Dakota preferred. This role is remote eligible and will require candidates to provide high-speed internet at their work location. ## Qualifications Preferred Qualifications - Great to have: * Prior health plan experience. Required Qualifications - Must have: * Associate degree or direct and applicable wo
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