Pge Jobs (NOW HIRING)

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As a Health Services Coding Analyst, you will provide clinical leadership and subject-matter expertise to support the analysis, configuration, and administration of complex medical policy content within claims processing systems, including Plan General Exclusion (PGE) rules and FACETS table maintenance. You will ensure the accurate implementation of medical policies, review criteria, and authorization requirements, while maintaining the integrity of system infrastructure and serving as a key liaison between business and technical teams. To do this, you will research and analyze system and business issues, develop high-level requirements, test and implementsolutions, and audit and document outcomes. The Health Services Coding Analyst also serves as an expert resource for medical policy configuration and PGE coding, mentoring and training Coding Specialists, and providing policy-related training and support to operational partners such as customer and provider services.

Must be willing to work core business hours of 8 AM - 5 PM Central Time.

Candidates located in Iowa or South Dakota preferred. This role is remote eligible and will require candidates to provide high-speed internet at their work location.  

Preferred Qualifications - Great to have:

• Prior health plan experience.

Required Qualifications - Must have:

• Associate degree or direct and applicable work experience preferred.
• Certified Professional Coder (CPC) required.
• Clinical background which may include either formal education or training in a clinical or health-related discipline (such as nursing, medical assisting, surgical technology, health information management, or a related field) and/or direct work experience in a clinical or healthcare setting.
• 7+ years’ or related health care experience in provider payment, claims, medical coding, or similar.
• Demonstrated expertise and knowledge of medical coding and terminology.
• Demonstrated strong attention to detail with the ability to multitask.
• Strong interpersonal skills including clear and concise written and verbal communication.
• Inquisitive nature, enthusiastic about developing and enacting new processes.
• Strong workflow management skills with sense of ownership, drive and initiative to continuously improve outcomes.
• Ability to communicate concepts clearly and concisely to individuals and groups and motivate others to achieve success with an eye toward promoting a culture of collegiality and excellence.
• Demonstrated ability to obtain relevant information by relating and comparing data from different sources.
• Proficiency in Microsoft Office applications including experience with spreadsheets, process mapping, presentation and word processing.
• Ability to adhere to quality and production metrics.
• Some experience with and continued interest in coaching and mentoring others.
• Demonstrated ability to consistently meet department work schedule.

What you will do:

a. Leadership in Coding Analysis: 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.
b. Maintain the claims processing system infrastructure to ensure compliance with regulatory and accreditation bodies and vendor supported technical requirements and ensure accurate claims adjudication.
c. Translate complex medical policy language into precise, actionable coding criteria for integration into claims systems and configuration platforms.
d. Serve as coding subject matter expert for complex or escalated utilization management.
e. Collaborate with Utilization Management nurses, medical directors, and claims teams to resolve coding-related denials, overrides, and policy interpretation questions.
f. 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, HCPCS).
g. Conduct impact analyses of proposed policy changes on coding, reimbursement, and operational workflows.
h. 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.
i. Maintain coding integrity by monitoring utilization trends to identify and resolve system configuration issues.
j. Work with Medical Policy Leadership in the development and optimization of coding configuration standards and best practices.
k. Work with payment integrity, business support, and data analytics teams to edit, develop, and implement Optum, Cotiviti, and Cognizant edits.
l. 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.
m. 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.
n. Participate in cross functional meetings or initiatives to support the goal of managing medical benefit expense.
o. 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.
p. 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.
q. Other duties as assigned.

Remote Eligible: You will have the flexibility to work where you are most productive. This position is eligible to work fully remote. Depending on your location, you may still have the option to come into a Wellmark office if you wish to. Your leader may ask you to come into the office occasionally for specific meetings or other ‘moments that matter’ as well.  

An Equal Opportunity Employer

The policy of Wellmark Blue Cross Blue Shield is to recruit, hire, train and promote individuals in all job classifications without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or any other characteristic protected by law.

Applicants requiring a reasonable accommodation due to a disability at any stage of the employment application process should contact us at careers@wellmark.com

Please inform us if you meet the definition of a "Covered DoD official".

At this time, Wellmark is not considering applicants for this position that require any type of immigration sponsorship (additional work authorization or permanent work authorization) now or in the future to work in the United States. This includes, but IS NOT LIMITED TO: F1-OPT, F1-CPT, H-1B, TN, L-1, J-1, etc. For additional information around work authorization needs please refer to the following resources:Nonimmigrant Workers and Green Card for Employment-Based Immigrants 

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