The Sr Operations Coding Analyst’s primary responsibilities require independent judgement in making complex coding-based decisions on claims and appeals to maintain and enhance Healthfirst’s claims editing systems in ensuring proper claims payments, reviewing, researching, and responding to written and emailed correspondence from providers regarding claim denials, and acting as a subject matter expert handling more complex provider issue. The Sr. Analyst will work as a first point of contact and provide day-to-day guidance to more junior Claims Coding Analysts. They are involved in setting Healthfirst claims policy and ensure that Healthfirst payment policy is aligned with CMS (Centers for Medicare and Medicaid Services), New York State Department of Health (NYSDOH), and all CPT, HCPCS, and ICD-10 coding guidelines, among others.
** This position is Remote
Duties & Responsibilities:
- Conducts independent assessments of current claims edits to ensure comprehensive and defensible claims editing is in place across all Healthfirst product lines
- Participate in special projects and advanced Claims Coding activities
- Proactively identifies areas of opportunity with respect to new edits, modifications to existing edits, and recommended claims policy changes
- Leads implementation efforts with respect to new or modified edits and works with other departments to ensure proper integration with existing systems and edits
- Monitors and reports on performance of current claims editing packages to substantiate savings to Healthfirst
- Serves as a subject matter expert to defend claims payment policy disputes and appeals
- Reviews claims editing escalated provider disputes/appeals and provides guidance on coding rules and industry standards across all areas of the company with regards to claims editing and proper coding, billing, and payment
- Researches and provides feedback on claims editing performance issues, both internally and externally with providers, vendors, etc.
- Collaborates with claims editing vendors to maintain and update edits as changes in the regulatory, legislative, or industry accepted payment policy requires
- Collaborates with other departments to improve compliance with coding conventions and clinical practice guidelines
- Leads continuous improvement and quality initiatives to improve processes across departments.
- Reviews and responds to written provider disputes, clearly and articulately outlining the payment discrepancy to the provider
- Able to participate and lead meetings with providers to explain coding issues and policies
- Thoroughly researches post payment claims and takes appropriate action to resolve identified issues within turnaround time requirements and quality standards
- Navigates CMS and State specific websites, as well as AMA guidelines, and compares to current payment policy configuration to resolve the provider payment discrepancies
- Reviews medical records to ensure coding is consistent with the services billed and compares against the clinical coding guidelines to determine if a claim adjustment is necessary
- Identifies and escalates root cause issues to supervisor for escalated review.
- Reviews and responds independently to internally escalated provider disputes transferred by management and other associates.
- Mentor other coders within the team
- Additional duties as assigned
Minimum Qualifications:
- Coding certification from either American Academy of Professional Coders (AAPC), Certified Professional Coders (CPC) or American Health Information Management Association (AHIMA)
- Previous Coding work experience
- High school diploma or GED from an accredited institution
Preferred Qualifications:
- Bachelor’s degree in related field
- Time management, critical/creative thinking, communication, and problem-solving skills
- Demonstrated professional writing, electronic documentation, and assessment skills
- Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills
- Knowledge of anatomy and pathophysiology medical terminologies
Compliance & Regulatory Responsibilities: See Above
License/Certification: See Above
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.
EEO Law Poster and Supplement
All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.
Hiring Range*:
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Greater New York City Area (NY, NJ, CT residents): $81,100 - $117,470
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All Other Locations (within approved locations): $71,600 - $106,505
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.
Top Skills
What We Do
Healthfirst is a provider-sponsored health insurance company that serves 1.8 million members in downstate New York. Healthfirst offers top-quality Medicaid, Medicare Advantage, Child Health Plus, and Managed Long Term Care plans. Healthfirst Leaf Qualified Health Plans and the Healthfirst Essential Plan are offered on NY State of Health, The Official Health Plan Marketplace. Healthfirst offers Healthfirst Pro and Pro Plus, Exclusive Provider Organization (EPO) plans for small-business owners and their employees, and Healthfirst Total, an EPO for individuals.
For more information on Healthfirst, visit www.healthfirst.org
