Job Description

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

Residency in or relocation to Louisiana is preferred for all positions.

POSITION PURPOSE

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.

NATURE AND SCOPE

• 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.

QUALIFICATIONS

Education

• High School Diploma or equivalent is required.

Work Experience

• 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.

Skills and Abilities

• 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.

Licenses and Certifications

• 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.

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

• 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.

Additional Accountabilities and Essential Functions

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

• 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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An Equal Opportunity Employer

All BCBSLA EMPLOYEES please apply through Workday Careers.

PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)

Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.

In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.

JOB CATEGORY: Insurance

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