Wellmark, Inc.
Health Services
HealthServicesCodingAnalyst(CPCRequired)
Neural analysis suggests this role is
optimal for mid candidates.
“Health Services Coding Analyst (CPC Required) at Wellmark, Inc.. Skills: Medical policy analysis, Claims system configuration, Coding expertise. Provide clinical leadership and subject-matter expertise. Support analysis, configuration, and administration of medical policy”
What You'll Achieve.
Continuously improve outcomes
Industry & Context.
Analyze system issues; Analyze business issues; Resolve coding-related denials; Resolve policy interpretation questions; Resolve complex claims issues; Resolve customer issues; Resolve provider issues; Identify and resolve system configuration issues
Core business hours 8 AM - 5 PM Central Time, Provide high-speed internet
What They're Looking For.
Must Have
Certified Professional Coder (CPC) required, Associate degree or direct and applicable work experience, Clinical background (formal education or training in a clinical or health-related discipline and/or direct work experience in a clinical or healthcare setting), 7+ years’ or related health care experience in provider payment, claims, medical coding, or similar, Demonstrated expertise and knowledge of medical coding and terminology, Demonstrated attention to detail with the ability to multitask, interpersonal skills including clear and concise written and verbal communication, Inquisitive nature, enthusiastic about developing and enacting new processes, workflow management skills with sense of ownership, drive and initiative to continuously improve outcomes, Ability to communicate concepts clearly and concisely to individuals and groups and motivate others to achieve success with an eye toward promoting a culture of collegiality and excellence, Demonstrated ability to obtain relevant information by relating and comparing data from different sources, Proficiency in Microsoft Office applications including experience with spreadsheets, process mapping, presentation and word processing, Ability to adhere to quality and production metrics, Demonstrated ability to consistently meet department work schedule
Nice to Have
Prior health plan experience, Candidates located in Iowa or South Dakota preferred
What You'll Do.
Provide clinical leadership and subject-matter expertise
and administration of medical policy
Ensure accurate implementation of medical policies
Maintain integrity of system infrastructure
Serve as liaison between business and technical teams
Research and analyze system and business issues
Develop high-level requirements
Test and implement solutions
Audit and document outcomes
Serve as expert resource for medical policy configuration
Mentor and train Coding Specialists
Provide policy-related training and support to operational partners
Lead analysis of complex medical policy content
Implement system edits to support policy intent
Assure compliance of medical policy coding requirements
Maintain claims processing system infrastructure
Ensure compliance with regulatory and accreditation bodies
Ensure accurate claims adjudication
Translate complex medical policy language into actionable coding
Serve as coding subject matter expert for escalated
Collaborate with Utilization Management nurses
Resolve coding-related denials
and policy interpretation questions
Contribute to medical policy creation
Draft coding sections
Research emerging procedures/devices
Ensure policies reflect current coding conventions
Conduct impact analyses of proposed policy changes
Provide medical coding expertise and PGE rule knowledge
Resolve complex claims and/or customer and provider issues
Monitor utilization trends to identify and resolve system
Develop and optimize coding configuration standards and best
Serve as primary points of contact and Subject
Provide expertise to support claims processing systems
Support regulatory requirements
FEP and Blue Card guidelines
Participate in cross functional meetings or initiatives
Support the goal of managing medical benefit expense
Provide expertise in medical coding PGE rule knowledge
Support projects and organization initiatives
Consult with leadership as business decisions are made
Retain and archive documentation of decisions made
Comply with regulatory standards
accreditation standards and internal
Remain current and consistent with standards pertinent to
Mentor and train Coding Specialists
Provide specific topic training related to medical policy
How You'll Work.
Team & Collaboration
Business and technical teams; Utilization Management nurses; Medical directors; Claims teams; Health Services leadership; Medical Review staff; Claims and Customer/Provider Services; Network Engagement; Payment integrity teams; Business support teams; Data analytics teams; UM Product Team; Cross functional meetings
Communication Scope
Written communication; Verbal communication; Clear communication; Concise 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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