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