Senior Clinical Coding Nurse

Join us in powering the future of healthcare cost containment.

Exponent Health (formerly HRGi Holdings, Inc.) has an exciting full-time opportunity for Senior Clinical Coding Nurse Consultant. Our team of brilliant professionals are continuously expanding the boundaries of the healthcare industry through innovations that intersect data and technology and amplifies human intelligence to result in better outcomes. We need people like you to join in our commitment to drive pure exponential value for our clients and partners.

Are you up for the challenge?

You'll work in a highly collaborative and creative Operations Product and Policy team comprised of talented healthcare coding and reimbursement professionals to maximize the businesses' opportunity for revenue and profits. Use creativity and innovation to solve problems in ways that have never been imagined before. Build relationships with key stakeholders, deliver visibility across the entire revenue team, improve efficiency across the revenue process, and become the analytical hub of the company.

You will have the chance to work with cutting edge technologies in an innovation driven environment where the team works collaboratively to solve challenges to achieve common goals. In this role you will:

1. Deliver and Execute (75%)- Assist the Director of Product, Policy, and Strategy in the revenue recognition directly related to Medical Cost Containment; Support the federal and state balance billing negotiations and mediation process, analytics, and building and maintaining Medicaid product lines; Leverage advanced clinical and medical coding skills to translate raw, often ugly, data into valuable business insights to drive strategic decision-making; Follow best practices established by the organization and participates in improvement conversations; Consistently helps the team achieve results, even under tough circumstances

1. Learns and Grow (20%) - Learns through successful and failed experiment when tackling new problems; Actively seeks ways to grow and be challenged; maintains the any clinical and/or coding certification credentials

1. Plan and Align (5%) - Builds partnerships and work collaboratively with others to meet shared objectives; Works across functions and supports client first mindset; Relates openly and comfortably within diverse groups of people, including but not limited to information technology, the negotiations and/or Medicaid teams, the audit team, and/or clinical pharmacy team

This role will require limited travel (up to 5%).

What you bring

To be successful in this role you'll need:

• Strong knowledge of CPT, HCPCS, DRG, and ICD-10 Codes
• Ability to perform coding audits and communicate findings verbally or in writing to providers, clients, government regulators, and/or internal stakeholders
• Self-starter with the ability to independently work urgently approaching deadlines and in a team
• Knowledge of compensability and relatedness for workers' compensation and/or automobile medical services
• Strong knowledge of Medicaid, Medicare, group health, contracts, letters of agreement, and/or legal/regulatory interpretation
• Strong knowledge of Medicare fee schedule development and gaps recommendations
• Exceptional knowledge of NCCI edits tables and policy manual with knowledge of AMA CPT Assistant
• Experience interpreting and/or applying cross coding methodologies for reimbursement gap logic

Responsibilities

• Partner with other business units to ensure compliance with implementing, adopting, or expanding on the rules and/or regulations, including but not limited to policies, procedures, and contracts
• Provide consultation internally or externally where appropriate
• Develop and implement market business plans to motivate providers and/or payers to engage in improving healthcare cost containment for better patient experience
• Provide analytical interpretation of coding compliance outcomes, executive summaries, and/or education to payers and providers
• Subject Matter Expert (SME) for internal departments on coding and complexity of services, including but not limited to regulatory scope for balance billing laws
• Assist in developing of training and analytical around coding and billing in balance billing laws and gaps in various fee schedules for audit or product development
• Lead Weekly, Monthly, Bi-monthly, Quarterly, and / or Annual Business Review meetings related to Coding or Clinical activities which summarize product, client, or market performance
• Analyze and evaluate provider characteristics, payers, and coding complexity to identify the most effective approaches and strategies related to reimbursement methodologies
• Analyze billing patterns and claims characteristics to determine areas of focus or improvement opportunities
• Develop solution-based, user-friendly initiatives to support existing products or product development, including but not limited to Managed Medicaid
• Other duties as assigned or requested

Required Expertise

• Certified Professional Coder (CPC) or other coding-related designation through the AAPC or AHIMA
• Experience utilizing accounting software to ensure accurate monthly close
• Bachelor's Degree in Nursing or Nursing Diploma from an accredited nursing school
• Strong analytical ability
• Experience with pharmaceutical drugs

Preferred Skills

• 7+ Years with current or former healthcare fraud, coding, and billing experience
• 5+ Years working with various medical reimbursement methodologies
• 3+ Years performing utilization review or crafting medical policies
• 5+ Years as a current or former clinical nurse with patient experience
• 3+ Years working with CMS rules and regulations
• 1+ Years of Operational Process Improvement Initiatives
• Strong written and oral communication skills
• Intermediate or Advanced knowledge of Excel, PowerPoint, and Word
• Experience managing or leading others preferred but not required

What it's like to work with us

Exponent Health has been challenging the industry status quo for over 30 years, leading with ground-breaking innovation in a wide variety of healthcare cost-management solutions. Embracing the latest opportunities that technology can offer within a rapidly evolving industry, we provide exceptional service, technology, and product innovation to meet greater challenges in healthcare cost management.

We have a distributed workforce so you can work from anywhere in the continental United States. Because of our distributed nature we have cultivated a connected culture that includes town halls, one-on-ones with executive leadership, educational forums, and even social clubs.

We offer comprehensive benefits package which includes the following:

• Medical, dental, and vision insurance
• Short term disability and long-term disability
• Life insurance and AD&D
• Supplemental life insurance (Employee/Spouse/Child)
• Healthcare and dependent care Flexible Spending Accounts
• Healthcare Savings Account
• Pre-tax commuter and parking benefits
• 401(k) Savings and Investment Plan with company match
• Paid time off