Clinical Policy Coding Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Assist the Clinical Policy team by ensuring precise coding of Clinical Coverage Guidelines and Claims Edit Guidelines.

• Manage authorization tools, such as the Auth Lookup Tool and Quick Reference Guides.

• Assess and refresh evidence-based clinical policies, coding standards, regulations, and authorization protocols.

• Spearhead the revisions and creation of Claims Edit Guidelines.

• Investigate state and federal regulations, coding industry standards, and related policies.

• Facilitate clinical decision-making through evidence-based criteria and authorization protocols.

• Supervise the transfer of guidelines to the Coding Integrity team and confirm that system edits are executed.

• Assist the Chief Medical Director with projects, vendor coordination, Medical Expense Initiatives, strategic initiatives, Medicaid admissions, and authorization policies.

• Review claims coding rule-change requests from clinical, financial, and claims operations viewpoints.

• Provide regulatory and coding research for Medical Expense Initiatives and contractual or implementation modifications.

• Act as the coding subject matter expert for markets and departments, aiding operations, product development, implementation, health outcomes, and growth initiatives.

• Support Medicare pre-service turnaround time and appeals initiatives and standardize authorization processes.

• Implement CMS risk adjustment guidelines and evaluate the effects of ICD codes on the CMS HCC risk adjustment model.

• Coordinate efforts to fulfill contractual, regulatory, and internal benchmarks.

• Deliver clinical policies to the Medical Management Platform and Digital Communications, ensuring both access points are audited for accuracy.

• Prepare Clinical Policy Updates for markets and leadership.

• Serve as a liaison between Medical Management and Systems Integration on coding inquiries.

• Engage in cross-functional projects involving Claims, Product, Operations, markets, and Medicare Planning.

• Assist with logistics and provide expertise in coding and claims payment on the Medical Policy Committee and Claims Payment Policy Committee.

• Communicate policy changes to markets and gather feedback.

• Perform additional duties as assigned.

⛳️ Requirements

• Associate's Degree in a relevant field or equivalent experience.

• 4+ years of experience in medical coding within a facility, provider, or payer organization.

• Knowledge of Medicare and Medicaid programs.

• A required license or certification: RHIA, RHIT, CCS, CCS-P, CPC, or CPC-H.

• Capability to meet productivity and accuracy benchmarks.

• Ability to justify coding decisions during internal and external audits.

• Comprehensive understanding of CMS risk adjustment guidelines.

• Familiarity with ICD codes and their influence on the CMS HCC risk adjustment model.

• Ability to comply with contractual, regulatory, and internal departmental requirements.

• Must be authorized to work in the U.S. without current or future employment-based visa sponsorship.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off.

• Holiday benefits.

• Flexible work arrangements including remote, hybrid, field, or office work schedules.

• Additional incentive programs may be included in total compensation.