Business Process Specialist
• Functions include skill sets tied to claims, Payment Integrity, Coding, and Business Process Analyst functions
• Collaborate system and data configuration with partners, perform user acceptance testing, and analyze post production reports for issues
• Develop enhanced, customized prospective medical coding and reimbursement policies and necessary coding configuration requirements
• Use and maintain reimbursement policy library and be a SME on coding guidelines and impact to provider reimbursement.
• Analyze, measure, manage, and report outcome results on system configuration / edits implemented.
• Knowledge and experience of claim operations, health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare)
• Medical Coding, Compliance, Data Analytics
• Direct and relevant experience with HCFA/UB-04 claims management, coding rules and guidelines, and evaluating/analyzing claim outcome results for accurate industry standard coding logic and policies (i.e . Center for Medicare & Medicaid Services (CMS) & MA Medicaid, Correct Coding Initiative (CCI), Medically Unlikely Edits (MUEs) both practitioner and facility, modifier to procedure validation, and other CMS and American Medical Association (AMA) guidelines, etc.)
• Certified Professional Coder (CPC)
• Certified Inpatient Coder (CIC)
• Certified Professional Medical Auditor (CPMA)
• Experience with Texas Medicaid
• Experience in Tapestry (Preference)
