Responsibilities
- Lead the analysis of the most complex Wellmark medical policy content and implementation of system edits to support its intent. Medical policy coding requirements are implemented, tested, documented and audited to assure compliance.
- Maintain the claims processing system infrastructure to ensure compliance with regulatory and accreditation bodies and vendor supported technical requirements and ensure accurate claims adjudication.
- Translate complex medical policy language into precise, actionable coding criteria for integration into claims systems and configuration platforms.
- Serve as coding subject matter expert for complex or escalated utilization management.
- Collaborate with Utilization Management nurses, medical directors, and claims teams to resolve coding-related denials, overrides, and policy interpretation questions.
- Contribute to the full lifecycle of medical policy creation, revision and interim review, including drafting coding sections, researching emerging procedures/devices, and ensuring policies reflect current coding conventions (AMA CPT, ICD10, HC游戏副本, HCPCS).
- Conduct impact analyses of proposed policy changes on coding, reimbursement, and operational workflows.
- Work directly with Health Services leadership, Medical Review staff, leadership within Claims and Customer/Provider Services and Network Engagement, Medical Directors to provide medical coding expertise and PGE rule knowledge to resolve complex claims and/or customer and provider issues.
- Maintain coding integrity by monitoring utilization trends to identify and resolve system configuration issues.
- Work with Medical Policy Leadership in the development and optimization of coding configuration standards and best practices.
- Work with payment integrity, business support, and data analytics teams to edit, develop, and implement Optum, Cotiviti, and Cognizant edits.
- Contribute to the achievement of corporate and UM Product Team objectives by independently serving as primary points of contact and UM Product Team Subject Matter Expert/Guest Star to provide expertise to support the various claims processing systems, including but not limited to PGE rules and table maintenance (FACETS and STAR). This will include attendance to various virtual cross-functional team meetings, as well as in-person attendance and participation in quarterly Iteration Planning meeting.
- Update coding files as required by code set revisions, HIPAA-AS, medical policy development and implementation, regulatory requirements, FEP and Blue Card guidelines, or as needed to support other internal processes.
- Participate in cross functional meetings or initiatives to support the goal of managing medical benefit expense.
- Provide expertise in the areas of medical coding PGE rule knowledge and medical policy configuration rules to support projects and broad organization initiatives. Consult with leadership as business decisions are made and retain and archive documentation of decisions made. Comply with regulatory standards, accreditation standards and internal guidelines; remain current and consistent with the standards pertinent to the Medical Policy team.
- Mentor and train Coding Specialist as well as provide specific topic training related to medical policy administration/PGE rules to other operational areas such as customer and provider service as needed.
- Other duties as assigned.
Work Arrangement
Remote (Worldwide)
Additional Information
- High-speed internet required at work location
- Core business hours: 8 AM - 5 PM Central Time
- In-person attendance required for quarterly Iteration Planning meeting
