Planned Systems International

Medical Claims Reviewer

Location US-Remote
Posted Date 1 month ago(1/24/2024 4:52 PM)
Job ID
2024-10456

Overview

SCOPE OF WORK

The Analyst II “QMPE Claims Reviewer” position will be filled by a health professional with experience in medical coding/billing and health plan program administration to serve as a medical coding/billing specialist in the Quality Management and Program Evaluation Unit, assisting with work within the Medical Benefits and Certifications Unit. The Analyst II “QMPE Claims Reviewer” position will participate in all aspects of managing the diagnostic and treatment benefit of a federal health plan making recommendations on requests for additions to the codebook and provide recommendations for prior authorizations requests to provide health care benefits to responders and survivors of the 9/11 attacks. Recommendations will be made based on policy, program statute, collaboration with experts, clinical research and the Analyst II “QMPE Claims Reviewer” medical and professional judgment. Additional duties include managing complex program deliverables, analyzing and manipulating medical claims data, and collaborating with occupational health subject matter experts. The Analyst II “QMPE Claims Reviewer” will interface with clinicians, medical administrators, and a diverse set of federal and contract staff. The work requires excellent organizational, verbal and written communication skills, attention to detail, innovative problem solving, and self-initiation. Guidance will be provided by the WTC Health Program leadership and management team, commensurate with level of duties. 

The contractor is to maintain a healthy organizational culture in providing consistent and professional communication and services to WTC Health Program clients including health care beneficiaries and health care providers, the contractor shall participate in the occasionally held lunch/learn and other training sessions regarding WTC Health Program organizational culture.

Duties:

•              Serves as an expert to senior management on categorizing diagnosis and treatment codes, managing codebook based on official coding conventions and federal health plans.

•              Serves as an expert to the Program on claims processing and reviews/audits; supports Program claims reviews

•              Monitors government and industry for information on current and correct code assignments, and utilizes such information and expertise to analyze Program evaluation and analysis reports as needed

•              Conducts clinical research for ICD, HCPCS, CPT, DRG code requests and makes final decisions

•              Conducts clinical research for ICD, HCPCS, CPT, and DRG prior authorization requests and claims review result inquiries, makes recommendations in writing to senior management.

•              Conducts research on federal payor coverage determinations for development of policy and procedure. Presents to the SMEs on possible solutions for coverage.

•              Reviews prior authorizations for completeness and alignment with Program requirements, makes recommendations to program for approval/denial using clinical and professional judgement

•              Makes final recommendations to the program on appropriateness for services within treatment/benefit plans using medical coding knowledge and experience.

•              Identifies and refer cases for higher review to subject matter experts.

•              Remain up to date with knowledge of ICD-10-CM/PCS and AMA CPT coding guidelines.

•              Works independently, multi-task, problem solve and make informed and accurate recommendations to medical professionals based on current information. Provides analytic support of cost and utilization reporting

•              Understands complex legislative, regulatory, and/or policy guidance for use in executing daily activities 

•              Monitors, coordinates, track multi-functional program deliverables, ensuring deadlines are met

The work entails both clinical and administrative aspects of health care delivery within a federal managed care system and involves collaboration with both clinicians and medical administrators. The WTC Health Program Quality Management & Program Evaluation Unit Chief with support from Medical Benefits and Certifications Unit Chief will provide support and guidance to the contractor in the performance of these deliverables. 

Organizational Context:  This work is for the WTC Health Program only and work will be related to the support of this specific program-area medical management process of maintaining the health plan codebook and participating in prior authorization review and research. The work will likely include collaboration with other WTC Health Program personnel that work on the team. 

Special Considerations or Requirements: The knowledge, skills and abilities are specific in this task area and shall include:

•              A bachelor’s or master’s degree in a health profession (HIM, MPH, MHA, RN, PA, other health profession) preferred

•              5+ Experience working with payor claims data in a health plan or managed care setting and/or experience in healthcare quality and auditing

•              Demonstrated expertise is in CPT, HCPC and ICD billing codes, authorization requirements and documentation, DRG and health care claims data analysis

•              Registered health information administrator (RHIA), Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) certification desirable

•              Proficient in Microsoft Office Suites, including Excel, Outlook, SharePoint

Company Benefits

PSI offers full-time, benefits eligible employees a competitive total compensation package that includes paid leave, and options for employer sponsored group medical, dental, vision, short-term and long-term disability, life insurance, AD&D coverage, legal services, identity theft, and accident insurance. Flexible spending account and health saving account options offer pre-tax savings for qualified medical, dental, and vision expenses. The company sponsored 401(k) retirement plan has an employer contribution match that is immediately vested. We invest in the professional growth of our employees through professional courses, certifications, and tuition reimbursement programs.

EEO Commitment

It is company policy to promote equal employment opportunities. All personnel decisions, including, but not limited to, recruiting, hiring, training, promotion, compensation, benefits, and termination, are made without regard to race, color, religion, age, sex, sexual orientation, pregnancy, gender identity, genetic information, national origin, citizenship status, veteran status, protected veteran status, disability, or any other characteristic protected by applicable federal, state, or local law.

Reasonable accommodations for applicants and employees with disabilities will be provided. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact Human Resources by emailing HRDepartment@plan-sys.com, or by dialing 703-575-8400.

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