Certified Coding Analyst

Position Purpose: 

Perform review of high dollar claims. Review for appropriate place of service, accurate coding, length of stay, match to authorization, and possible outlier DRG or Stop Loss pricing. Perform coding research. Conduct complex business and operational analyses to assure payments are in compliance with contract; identify areas for improvement and clarification for better operational efficiency resulting in better initiative, contract, and benefit implementation as well as better maintenance long term.

• Perform review of high dollar claims for benefit and pricing determination.

• Work collaboratively with Finance Department to determine appropriateness of pricing.

• Work collaboratively with Medical Management Department to resolve any issues with medical review notes that affect claim pricing

• Serve as a technical resource / coding subject matter expert for contract pricing related issues

• Responsible for entire cycle of facility claims which includes verifying information on submitted claims, reviewing contracts, eligibility, and authorizations to determine reimbursement, and ensuring payment instructions are sent to claims department for claims payment

• Identify key elements and processing requirements based on diagnosis, provider, contracts and policies and procedures utilizing broad based product or system knowledge to ensure timely payments are generated.

• Conduct point of service review and resolution of high dollar claims that are pending and/or adjusted incorrectly including review, investigation, adjustment and resolution of claims, claims appeals, inquiries, and inaccuracies in payment of claims.

• Collaborate with all departments to analyze complex claims issues and special claim projects.