Claims Coding Specialist

WellCare Health Plans Inc. Tampa, FL
Position is primarily responsible for reviewing, researching, and responding to written and emailed correspondence from providers, both professional and institutional, regarding claim denials based on clinical coding policies. Acts as a subject matter expert and handles more complex provider issues.

Essential Functions:

* Reviews and responds to written provider disputes, clearly and articulately outlining the payment discrepancy to the provider.

* Thoroughly researches post payment claims and takes appropriate action to resolve identified issues within turnaround time requirements and quality standards.

* Navigate CMS and State specific websites, as well as AMA guidelines, and compare to current payment policy configuration in order to resolve the providers payment discrepancy.

* Review medical records to ensure coding is consistent with the services billed and compares against the clinical coding guidelines in order to decide if a claim adjustment is necessary.

* Processes claim adjustment requests in Xcelys following all established adjustment and claim processing guidelines.

* Utilize SharePoint and Excel as necessary to work through daily inventory assignments.

* Identifies and escalates root cause issues to supervisor for escalated review.

* Reviews and responds to internal escalated provider disputes transferred by management and other associates.

* Acts as liaison with other departments when additional clarification is needed about claims payment policy disputes.

* Assists team members with training opportunities and coaching.

* Assists with special projects as assigned or directed.

Additional Responsibilities:Candidate Education:

* Required A High School or GED

Candidate Experience:

* Required 3 years of experience in claim coding, claim processing or billing in a healthcare environment

* Preferred 1 year of experience in claims coding

Candidate Skills:

* Intermediate Demonstrated written communication skills

* Intermediate Demonstrated interpersonal/verbal communication skills

* Advanced Knowledge of medical terminology and/or experience with CPT and ICD-9 coding

* Intermediate Other Ability to quickly research and absorb new payment systems

* Intermediate Other Knowledge of Medicare and Medicaid payment systems

Licenses and Certifications:

* Preferred CPC, CSS or relevant certifications

Technical Skills:

* Required Intermediate Other Strong knowledge of electronic medical records/billing systems and medical terminology and abbreviations

* Required Intermediate Other Billing expertise in UB92, UB04, HCFA 1500 and/or other healthcare services


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