Medical Coding Analyst

This position is responsible for working with the Senior Medical Coding Analyst by minimizing overpayments on medical claims for all lines of business by effectively working with internal teams and vendor partners to identify claims payment issues and correct root cause issues. Ensures correct medical coding and billing practices, and enforces member agreement compliance. This position will be mentored by the Senior Medical Coding Analyst on various coding and billing discrepancies which cause overpayments to providers such as misuse of unlisted codes, fragmented claims to avoid bundling and multiple procedure reduction logic and incorrect usage of modifiers.

• This role does not manage people
• This role reports to this job: Manager, Payment Integrity, Clinical or Manager, Utilization Review - Inpatient.
• Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with: All levels of providers, external consultants, attorneys, external auditors and BCBSLA personnel; which includes but is not limited to: Medical Directors, Providers, Appeals and Member Services area staff.

• High School Diploma or equivalent is required.

• 2 years of medical coding, auditing, medical claims processing and/or experience in an clinical insurance setting such as a Medical Review, Case Management, Utilization Review, Population Health or related managed care field is required. Prefer an LPN with a background of coding or auditing experience.
• Experience using Microsoft Office Suite software required.
• Advanced level experience with Excel, Access, SQL or other relational database software preferred.

• Must be detailed oriented with large sets of data.
• Proven analytical, organizational and interpersonal skills.
• Effective communication and training skills.
• Ability to independently coordinate audit priorities, handle multiple tasks concurrently and support departmental operations.
• Working knowledge of relevant software (Word, Excel) and ability to learn new applications is necessary.
• Must have strong oral and written communication, interpersonal and organizational skills.

• Certified medical coding designation such as Coding Professional Coder certification (CPC) or CPHC or attainment within 2 years is required.
• A Licensed Practical Nurse (LPN) license to practice in the state of Louisiana preferred.

• Utilizes information from claims data analysis to isolate and investigate medical claims payment anomalies, ensure compliant coding and billing practices, and enforce member agreement compliance.
• Determines root cause of medical claims over payments and develops recommendation to correct overpayments.
• Engages in provider relations activities which assist in provider and subscriber problem resolution.
• Maintains a thorough understanding of medical coding guidelines, provider operations and billing systems, contract benefits, claims procedures, provider contracts and reimbursement agreements.
• Assesses analytics and audit findings of vendor partners for patterns, and potential opportunities to minimize overpayment.
• Works with vendor partners to resolve audits and reviews in accordance with vendor contractual obligations.
• Investigates systemic issues and ensures resolution for all assigned provider inquiries and submissions.
• Implements solutions for payment integrity issues to prevent incorrect claim reimbursement.
• Researches, analyzes, interprets national medical coding guidelines and performs complex professional bundling appeals to ensure customer satisfaction and compliance with regulatory standards.
• Works CES and Avalon Provider Disputes.
• Develops and assists with customized code sets for BCBSLA medical policy, mainframe system edits, and CES.
• Identifies potential medical coding opportunities through trend analysis and makes recommendations to management on changes to computer logic to ensure efficiency and cost containment, benefit structure, and Claim Check.
• Works with Medical Coding committee, MCAC, and PA review for all Medical Policy and Coding issues/updates.

Based upon work location:

• Incumbent may focus primarily on inpatient claims.
• Incumbent will will handle the DRG Review Process: Performs clinical coding reviews, clinical report requests and DRG claims. Prepares DRG profiles from facility submitted claims for medical ddirector review, edit and complete all DRG's that have been completed by the medical director which requires entering their decision into the Acuity authorizations.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.

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