Providence Health & Services Coding Policy Analyst in Beaverton, Oregon
Providence is calling an Analyst-Coding Policy to Providence Health & Services in Beaverton, OR.
We are seeking an Analyst-Coding Policy to be responsible for the coordination of technically detailed work that has a significant impact on all operations and information systems within PHP. This includes assisting with edit configuration for PHP claims coding editing system, replying to provider and member payment appeals and providing appropriate CPT, CMS, specialty society, PHP Medical Director review, PHP payment policy, and/or other official documented rationale for upholding denials. This person assists with updating the company’s coding database with new, deleted, and revised codes as these are published throughout the year and informs appropriate parties at PHP when there are changes to this database. This position requires knowledge of CMS, Medicaid, and worker''''s compensation policies and regulations. This person serves as a resource to other departments within PHP for questions about CPT, HCPCS, ASA, and ICD-9/10 codes, as well as coding guidelines and regulations. Works with the Benefits Administration Team and the Regulatory Department to ensure coding edits are applied in a manner consistent with member benefits and all state and federal insurance regulations. This person assists with monitoring changes to codes, coding guidelines and regulations, and coding edits from external agencies such as AMA, CMS, Medicaid, and specialty societies, and assists with implementation of such changes to the claims adjudication software and coding editing software as needed.
In this position you will have the following responsibilities:
Responsible for assisting with writing, updating, maintaining, and implementing PHP Payment Policies based on industry standards, coding and payment rules and regulations, and Health Plan decisions made by PPRC and approved by the Medical Expense Management (MEM) committee.
Responsible for assisting with writing, updating, maintaining, and implementing PHP Medical Director edit reviews based on industry standards, coding and payment rules and regulations, and Health Plan decisions made by PHP Medical Directors.
Publish PHP Payment Policies and edit reviews on PHP website (ProvLink) and Premera MA’s website. Maintain updated policies and edit reviews on both online websites.
Run provider coding analyses as needed for edit reviews, payment policy updates, or in response to a provider’s request to bypass edits.
Respond to provider appeals related to Optum Claims Editing System (CES) or Facets edits maintained by Coding Compliance Department. If denials are upheld, write a letter to the provider containing rationale from payment policies, CPT coding guidelines, NCCI policies or edits, CMS rules and regulations, PHP Medical Director edit reviews, or specialty society coding edits to support the denial and cite the source of the rationale.
Maintain Excel spreadsheet with results of all provider appeals.
Required qualifications for this position include:
Baccalaureate degree or equivalent work experience in health care
5 years’ experience directly related to CPT coding from chart extraction with a health care provider, a health insurance company, or a capitated managed care company.
Excellent writing and grammar skills.
Demonstrated experience in detailed coding applications, as well as Microsoft Office capabilities, such as Excel, Word, and Access.
Extensive knowledge of AMA CPT coding guidelines and National Correct Coding Initiative policy guidelines and edits, as well as a working knowledge of CMS billing and coding rules and regulations.
Extensive knowledge of ICD-9 and ICD-10 diagnostic coding rules.
Extensive knowledge of reimbursement methodologies such as RVU, DRG, OPPS and HCC.
Ability to work in a close advisory role and/or as a team member with several departments/work units within Health Plan.
Excellent oral and written communication skills.
Strong analytical and mathematical skills.
Demonstrated organizational and problem-solving ability required.
Ability to work independently with minimum supervision.
Ability to work with all levels of management and staff.
Knowledge of regulatory and contract language and ability to analyze implications.
Preferred qualifications for this position include:
- Experience with Facets Claims Adjudication system and/or Optum CES editing software.
About the department you will serve.
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple, "Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
We offer a full comprehensive range of benefits - see our website for details
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence Health & Services is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and services guided by a Mission of caring the Sisters of Providence began over 160 years ago. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Coding
Req ID: 192377