Responsibilities
- Evaluate current and historical medical policies, transmittals, and bulletins to determine needed updates, including creating, revising, or retiring policies.
- Gather and interpret data from various sources to support rule logic development, documentation, and quality validation.
- Build and validate entries in the Clinical Transaction Engine tables used by medical necessity and claims processing systems.
- Assess modifications to medical procedure edits to ensure accurate alignment with varying ICD-10-CM diagnosis levels.
- Map CPT/HCPCS codes to PreCertification tables when only narrative clinical conditions are provided.
- Review national coverage determinations and assign relevant diagnosis and procedure codes for integration into Medicare medical edits.
- Independently develop, refine, and finalize data edits for deployment to production environments.
- Generate reports for leadership on coding trends, documentation standards, payer updates, and compliance concerns.
- Evaluate medical guidelines and literature for integration into designated databases.
- Detect recurring coding inaccuracies or policy flaws and propose corrective coding or structural improvements in diagnosis and procedure tables.
- Conduct thorough, independent analysis of issues escalated by Compliance Support teams.
- Draft and communicate responses to client inquiries and engage in related discussions.
- Ensure all medical rule content is accurately maintained in designated databases using internal software tools.
- Interpret healthcare data to form actionable insights and conclusions.
- Perform regular, precise research using authoritative sources to keep policy content current.
- Monitor evolving coding standards and industry developments to maintain policy accuracy.
Work Arrangement
Remote
