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1199SEIU Family of Funds: Business Systems Analyst Ii

1199SEIU Family of Funds

This is a Contract position in Fresno, CA posted January 10, 2022.

ResponsibilitiesAnnually and quarterly review and research, as necessary, all new CPT and HCPCS codes for coding logic, related Medicare policies, and rate information to enable the Chief Medical Officer to make coverage and reimbursement determinationsPerform comprehensive maintenance review on all Fund policies, HCPCS codes, Molecular Pathology and Proprietary Laboratory Analyses codes, Vaccine codes, Contraceptives/IUD codes and Radiopharmaceuticals which involves examining the codes to modernize coding reimbursement policies inclusive of coding regulations and coding configurationDevelop enhanced, customized prospective claims auditing and clinical coding and reimbursement policies, and the necessary coding configuration for Change Healthcare/McKesson’s Policy Management Module (PMM).

At least annually monitor, manage, measure, and analyze and report outcome results for the PMMs.

Develop documents as necessaryUtilize statistical data to examine large claims data sets to provide analyses and reports on existing provider billing patterns as compared to industry standard coding regulations; and make recommendations based on industry standard coding logic, business rules and Fund policyPerform complex compliance claims audits or clinical reviews on pended claims to investigate, research, and analyze CPT and HCPCS claims data.

When indicated, identify errors, wasteful/excessive billing practices on a claim, provider and/or code level.

This includes trouble shooting, resolving issue(s) and/or recommending corrective action for deficiencies, irregularities and anomalies.

Requires interpretation of industry standard health care coding conventions and Fund policiesCollaborate with different departments to define the Fund policy (PMM) criteria according to current and standard clinical coding rules/logic.

Interact with QNXT production department to perform pre and post testingUse and maintain the rules and Fund policies in ClaimsXten Select, the Fund’s advanced claim auditing software application.

This prospective application interfaces with a claims adjudication system to help ensure that the Fund’s clinical coding and claim editing logic are accurate and consistent with industry standard guidelines to ensure that claims are processed efficiently, and providers are reimbursed accurately.

Provide direction to the configuration team for required new edits and revisions to existing rules and PMMs.

Test the configurations which includes auditing, interpreting, and reporting the results to determine if the edits are being applied correctly.

This is an interdependent team approach with the configuration/production teamWork closely with management to develop manage and update operating procedures or other relevant documentation for program specific data management activities; monitor operational activities to ensure compliance with documented policies, procedures standards and quality improvement processes.

Generate timely reports, analyze and summarize cost savings reports, track and trend outcomes and recommend custom solutions for all clinical compliance initiativesCraft user manuals, policy, procedures, or other pertinent documentation to support clinical compliance initiativesTrain staff as necessaryDesign and conduct quality control and improvement activities (utility of software applications, report generation, test scenario development, check report results for quality, claims auditing, etc.), track and trends results, and recommend corrective action for problems, irregularities and anomaliesPerform additional duties and projects as assigned by management QualificationsBachelor’s degree in health care or related field or equivalent years of work experience requiredMinimum five (5) years senior level, progressive experience in medical outpatient claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review requiredDirect and relevant experience with HCFA claims management, coding rules and guidelines, and evaluating/analyzing claim outcome results for accurate industry standard coding logic and policies (i.E.

CCI, MUE, modifier to procedure validation, and other CMS and AMA guidelines, etc.)AAPC certification in professional medical coding requiredAdvanced experience of medical terminology and medical coding (CPT, HCPCS, Modifiers) along with the application of Medicare’s claims’ processing policies, coding principals and payment methodologiesAdvanced skill level in Microsoft Word and Excel requiredIntermediate level experience with Change Healthcare/McKesson claims auditing software programs preferredSolid aptitude in math with frequent use of calculation functions