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Waukesha Teller (30+)

BMC HealthNet Plan

Waukesha Teller (30+)

Charlestown, MA +1 location
Full Time
Paid
  • Responsibilities

    The Regulatory and Transaction Coding Manager is responsible for managing all aspects of claims based HIPAA code sets and cross-departmental implementation of billing code sets utilized in healthcare transactions for the plan. This individual will closely monitor reimbursement regulations and industry policy changes from HIPAA, Medicare & Medicaid, Official Coding & Reporting Guidelines, National Correct Coding and Industry coding standards to ensure all ancillary systems are aligned.

     

    The Regulatory and Transaction Coding Manager will be responsible for developing SOPs-standard operating procedures, lead system data audits, reconcile coding gaps, create new business processes/workflows, business and technical requirements and will lead cross-departmental review, operational assessment and implementation efforts to ensure timely and accurate completion of reimbursement regulatory and coding changes.  Additional specific duties and responsibilities include:  

     

    KEY FUNCTIONS/RESPONSIBILITIES:

    • Develops and maintains corporate transaction policies, and works collaboratively with stakeholders and department manager to ensure consistency with the Plan’s system(s).
    • Monitors sites and regulation governing healthcare transaction data to include AMA, CMS, NUBC, UB Editor, WPC DHHS, EOHHS, and, listservs and other sources to identify existing coding & payment practice and upcoming changes. Determine the scope and impact of the change on Plan operations and seek to implement changes as necessary.
    • Ensures all code sets stored in the Plan’s transaction processing system are accurate and up-to-date. Responsible for requirements development, follow through and testing support on end-to-end implementation of coding updates across all systems.
    • Act as an SME, support and responds to all code set inquiries and discrepancies.
    • Responsible for obtaining electronic copies of all code sets and facilitating required system updates to ensure continued HIPAA compliance.
    • Monitors and resolves claim processing errors related to code validation edits during adjudication.
    • Provides industry interpretive expertise in the evaluation of regulatory, coding and transaction based business rules.
    • Staff and participate in various work groups and committees to support coding policies and provides input into processes and workflows reliant on code based policy outcomes.
    • Serve as the department’s project manager for: (1) regulatory information such as proposed and final Medicare and/or Medicaid reimbursement and coding regulations, Medicare Manual code updates, DHHS and EOHHS transaction code changes. Determine the scope and impact of the information/issues and take appropriate action.
    • Collaborate with Public Partnerships, Contracting, Finance, Provider Relations, Product Administration, Configuration, and Provider Audit/OPL to determine the impact of implementing recommended policy changes.
    • Develop project plans including: setting timelines and deliverables; determining resource requirements; documents decisions; draft communication plan; information-sharing with appropriate staff and seek approval from Governance; and subsequently ensure successful completion of change.
    • Serve as the company’s research specialist regarding industry standard code set policies.
    • Submits recommendations to the Payment Policy Committee and supports Committee efforts through subgroups and individually as needed.
    • Collaborate with stakeholder departments to develop and maintain a database to serve a centralized location to store coding truth source information.
    • Key point of contact for Configuration analysts on testing and use of correct coding to ensure proper configuration ensued. Assist configuration analysts on all requests; i.e. modifier and revenue code combinations.
    • Key point of contact for outside departments: Claims, Provider Relations, Customer Care, and Contracting; researches all requests triggered from coding denials and potential configuration issues.

     

    QUALIFICATIONS:

    _ _

    EDUCATION:

    • AHIMA or other nationally recognized Coding Certification.
    • Bachelor’s Degree in a related field or the equivalent combination of training and experience.
    • Master’s Degree or graduate work in a related field preferred.
    • Coding Certification for Payers – CPC-P preferred.

    EXPERIENCE:

    • 8 or more years experience in a fast paced, managed healthcare environment is required.
    • At least 6 years direct work in claims processing, payment policy, or contracting.
    • Extensive background of ICD-10 and CPT coding principles.
    • Extensive knowledge of medical claim editing (NCCI, etc.)
    • Knowledge of  industry standard payment rules and methods.
    • Knowledge of Medicare, Medicaid and commercial coding rules/ regulatory requirements.
    • Ability to clearly communicate very complex coding and reimbursement terms to business units.
    • Medical chart auditing preferred.

    COMPETENCIES, SKILLS, AND ATTRIBUTES:

    • Demonstrated proficiency in coding and knowledge of the requirements of industry standards such as Medicare and/or Managed care regulations required.
    • Strong understanding of HIPAA Guidelines.
    • Good communication skills, both oral and written, ability to interact well with others at all levels, strong organizational skills, strong customer service skills and orientation.
    • Expertise utilizing Microsoft Office products, primarily Microsoft Word and Excel. 
    • Knowledge of Optum CES product, or similar claims editing system.

     

     

    *Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

    Required Skills Required Experience

  • Qualifications
    • Manage the infrastructure staff and monitor consulting outsource staff. The current Infrastructure team is a mix of Bi-State employees and consultants who are part of an outsource arrangement and work directly with us at our headquarters location. There are five employees and ten consultants. The team is responsible for Bi-State networks, servers, storage, telecom, helpdesk functions, desktop/PC support, printer support, data/network security, and internal/external access to Bi-State websites and applications. This role will ensure that critical activities are staffed, prioritized, communicated, and executed appropriately.
    • Coordinate with our outsource vendor to ensure that provided outsource staff are focused on assigned work, properly skilled, and meeting Bi-State policies and procedures. Assist with planning and execution of staff transitions on and off the team. Ensure billing and payments are accurate and timely. Provide prioritization of work assignments and suggestions for improvements for this outsource team.
    • Manage assigned employees. Management duties include: goal setting, performance monitoring, appraisals, and staffing recommendations for raises, promotion, training, and disciplinary actions.   Work with individuals to promote growth through appropriate assignments, feedback, self-study, and training.
    • Promote procedures, work, and technology approaches that ensure reliable/available technology and applications for Bi-State users and customers.
    • Participate with the IT management team in planning Production rollouts, ensuring all production outages are planned and coordinated with applicable parties, and downtime is minimized.
    • Participate as needed with business leaders and customer groups to understand new approaches and requirements that may be developing in Bi-State business areas.
    • Evaluate new technologies and approaches from peers and the industry. Develop technology roadmaps. Determine next steps to keep Bi-State solutions current and viable. Communicate future vision/direction to staff and work with CIO to find funding and promote changes.
    • Work in partnership with Information Security personnel to build our security capabilities and resources in conjunction with our information security roadmap.
    • Ensure key infrastructure projects are properly defined, resourced, and managed to completion.
    • Assess and communicate the impacts, tradeoffs, risks, costs, benefits and opportunities of IT Infrastructure solutions. Ensure existing components and software are upgraded and remain viable.
    • Plan and manage an annual budget of $2.5 to $3.0 million dollars. Use financial resources economically. Stay within budget specifications. Ensure infrastructure procurements meet Bi-State guidelines.
    • Anticipate potential problems and changes. Develop contingency plans to address these issues.
  • Locations
    Charlestown, MA • Boston, MA