Anthem Utilization Review Jobs (NOW HIRING)

Job Summary

The Coding Specialist reviews superbills and the corresponding medical record documentation and assigns appropriate CPT, HCPCS, modifiers, and ICD 10 codes and post charges in order to achieve maximum reimbursement in accordance with OSNI protocols and procedures along with CMS and private payer guidelines. The core responsibilities will include: daily charge posting after assignment of appropriate billing and diagnostic codes, review of first level rejected claims in practice management, use of hospital portals to obtain operative reports and patient demographics, scanning of completed work into SRS . Additional responsibilities include querying physicians and ancillary medical staff when medical record requires clarification, ensuring medical record is amended by provider when appropriate and participating in internal provider coding review sessions.

Qualifications:

• High school diploma or an equivalent combination of education and experience.
• RHIT, CPC, or CCS is required.
• Associate degree or higher in coding or health information management, accounting or business administration highly desired.
• Data entry skills (50-60 keystrokes per minutes)
• Past work experience of at least one year within a healthcare setting, an insurance company, managed care organization or other financial service setting, performing coding or billing functions is required.
• Knowledge of insurance and governmental programs, regulations and billing processes (e.g., CMS, Anthem, UHC, etc), managed care contracts and coordination of benefits is required.
• Thorough working knowledge of medical terminology, anatomy and physiology, medical record coding (ICD-10, CPT, HCPCS), and basic computer skills are required.
• Excellent communication (verbal and writing) and organizational abilities. Interpersonal skills are necessary in dealing with internal and external customers.
• Accuracy, attentiveness to detail and time management skills are required.

Responsibilities:

1. Knows, understands, incorporates, and demonstrates the OSNI Core Mission, Vision, and Values in behaviors, practices, and decisions.
2. Performs all coding functions, including CPT/HCPCS and ICD 10 code assignment in accordance with state, federal, and payer guidelines:
   1. Reviews medical record to ensure appropriate codes are utilized and documentation supports code use
   2. Assigns appropriate CPT, HCPCS, ICD-10 codes along with appropriate modifiers to capture service rendered
   3. Queries physicians and medical ancillary staff when necessary for clarification.
   4. These functions will be in coordination with the Business Office team.
3. Performs accurate charge data entry into practice management system
4. Reports missing data as required
5. Participates in internal provider coding review sessions
6. Reviews and corrects electronic first level claim rejections in practice management
7. Prints and mails paper claims with corresponding records as appropriate
8. Follows applicable coding guidelines and legal requirements to ensure compliance with federal and state regulations
9. Maintains thorough working knowledge of private payer guidelines
10. Remains apprised of changes to coding guidelines and code sets
11. Communicates with physicians and their office staff, Patient Access, Medical Records/Health Information Management, Utilization Review/Case Management, Managed Care, Ancillary and Nursing staff, as required to clarify discrepancies, and obtain demographic and clinical information.
12. May prepare special reports as directed by the Manager to document coding
13. May serve as relief support, if the work schedule or workload demands assistance to departmental personnel.
14. May also be chosen to serve as a resource to train new employees.
15. Cross- training in various functions is expected to assist in the smooth delivery of departmental services.
16. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, as well as OSNI’s Standards of Conduct, and other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
17. Other duties as needed and assigned by Billing Manager, Practice Manager, and/or CEO

Physical Requirements:

• Ability to fulfill any office activities normally expected in an office setting, to include, but not limited to: remaining seated for periods of time to perform computer based work, participating in filing activity, lifting and carrying office supplies (paper reams, mail, etc.)
• Fine hand manipulation (keyboarding)
• Must be able to set and organize own work priorities, and adapt to them as they change frequently.
• Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.
• Excellent problem solving skills are essential.
• Ability to comprehend and retain information that can be applied to work procedures to achieve appropriate service delivery.