Job Description

Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.

Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

Coordinates coding updates and assists in the establishment of reimbursement policies. Coordinates coding guidelines with medical policies and corresponding pricing functions.  Researches, supports, and implements changes related to corporate reimbursement strategy to ensure appropriate, accurate, and predictable provider reimbursement.

LEVEL 1

  • Research and help resolve pricing and coding inquiries or issues (HCPC, CPT, ICD9/ICD10, modifiers etc.). Research and provide recommendations for coding guidelines, industry standard coding practices, billing issues, and reimbursement, taking into consideration possible business implications.
  • Conduct coding and reimbursement research through the internet or various other sources, as available, including provider organizations, CMS, and other Blue Cross Blue Shield Plans. 
  • Research claims submissions for appropriate billing practices.   Help identify and communicate fraud and abuse issues related to coding.
  • Participate in the development of monthly, quarterly and annual coding updates. Track all potential coding changes, documenting details and decision points thoroughly, including timing and interdependencies with other coding, configuration or pricing processes. Review all potential changes with management or peers prior to finalization.
  • Compile the monthly, quarterly and annual coding updates in a timely manner and with 100% accuracy. Audit the implementation of coding updates to ensure accuracy and consistency with established reimbursement and coding policies.
  • Develop, maintain and follow detailed procedures on the process and business rules around coding changes.
  • Provide timely research and support for claims and customer service representatives' pricing questions.
  • Ensure timely and accurate maintenance of coding-related documentation for internal and external users.
  • Coordinate reimbursement and coding documentation updates and assist in the establishment of reimbursement policies.
  • Coordinate coding guidelines with medical policies and corresponding pricing functions.
  • Constantly pursue process and documentation improvements that will reduce or eliminate the potential for manual errors. Proactively partner with others to develop technical solutions to automate or streamline standard processes or decision points.
  • Attend pertinent coding seminars and training, and use other resources as applicable, to maintain current knowledge of rapidly changing coding guidelines.
  • Set up all work in such a way that it can be easily reviewed and recreated.

     

    LEVEL 2

  • Proactively review and identify potential revisions to existing coding and reimbursement rules and methodologies for improved consistency, thoroughness, accuracy and appropriateness. Constantly review CMS guidelines, other industry coding and reimbursement standards, online reference material, coding-related publications, and training material as part of this process
  • Participate in the analysis and support of the claim editing software, including obtaining edit clarification and coordinating coding and customization changes.
  • Develop and maintain a thorough understanding of how coding decisions affect pricing, reimbursement or other production processes. Become a Subject Matter Expert on and maintain documentation of these interdependencies.
  • Develop clear and concise recommendations for any potential coding or reimbursement changes including full rationalization and how it might interact with current processes and policies.
  • Independently represent coding and reimbursement team interests on cross-divisional committees or projects.
  • Participate in the annual DRG taskforce to identify new diagnosis codes, DRG and procedure codes for appropriate system action, providing critical guidance and support from the initial review and interpretation of CMS proposed changes through implementation of final DRG base rates.
  • Participate on the fee schedule team to develop market appropriate fees for all new and existing procedure codes, including annual professional and outpatient fee schedule updates.  In addition to team participation, participate subgroup to develop fee recommendations for non-CMS priced procedures without fees.  
  • Provide diagnosis code and code edit information for system and production support, which includes coordinating the pre-existing and waiver flags within the claims systems.
  • Demonstrate complete ownership and accountability in all leadership roles, process improvements and recommendations.
  • Develop clear and concise recommendations for any potential coding or reimbursement changes including full rationalization and how it might interact with current processes and policies. Present recommendations to the appropriate audience for review and approval.
  • Work closely with other areas of the company to ensure implementation and updates to methodologies are made timely and accurately.
  • Share knowledge of skills, projects, and business needs with peers and less experienced analysts.  Trains new analysts as needed

    ALL LEVELS

    Reports to a supervisor or manager who provides minimal supervision/project management. Develop own work-plans, and discusses timelines, prioritization, and objectives with supervisor or manager.
  • Each progressive level includes the ability to perform the essential functions of any lower levels and mentor employees in those levels.
  • The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
  • Perform all other duties as assigned.

BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Skills / Requirements

  1. Required Work Experience
  • 2 years of experience working for a healthcare organization / health insurer (All Levels)
  1. Required Education
  1. Required Licenses
  1. Required Certifications
  • Professional Coder Certification Exam, along with completion of the medical field experience requirement, resulting in certification from a professional coding institute/organization. (All Levels)
     
  1. Preferred Work Experience
    • 3 years of experience working for a healthcare organization / health insurer (All Levels)
    • 1 years of experience in an healthcare economics or payment integrity or actuarial field (All Levels)
    • Experience with coding of all claim types (All Levels)
  1. Preferred Education
    • Associate’s or Bachelor’s Degree in any general field of study. (All Levels)
  1. Required Job Skills (All Levels)
    • Intermediate skill in use of office equipment, including copiers, fax machines, scanners and telephones
    • Intermediate PC proficiency
  • Intermediate proficiency in spreadsheet and word processing software
  • Basic skill in mathematics
  1. Required Professional Competencies  (All Levels)
    • Broad understanding of health insurance terms and concepts
    • General knowledge of the healthcare industry
    • Knowledge of coding principles and code sets including UB92, CPT, HCPCS , ICD 9/10, ADA, and ASA
    • Knowledge of UB92 guidelines.  Knowledge of Medicare rules and regulations
    • Ability to deal with ambiguity and make recommendations with less than complete or conflicting information while maintaining appropriate time management
    • Ability to maintain confidentiality and privacy
    • Ability to communicate effectively, both orally and in writing, to peers and direct management
    • Ability to build and maintain productive working relationships with others
    • Skill in prioritizing tasks and working with multiple priorities, sometimes under limited time constraints
    • Ability to summarize coding information to a general audience
    • Proactive about requesting enough information to fully understand and meet the business need
 

Application Instructions

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