Claim Edit and Vendor Integrity Specialist, Geisinger Health Plan ( Eastern Unit

Location: Work from home (Pennsylvania) Shift: Days (United States of America) Scheduled Weekly Hours: 40 Worker Type: Regular Exemption Status: Yes Job Summary: Our successful candidate has experience collaborating with external vendors in a healthcare claims or payment integrity environment, including implementation support, claim-edit validation, issue escalation and resolution, performance monitoring, and ongoing vendor relationship management. Job Duties: Acts as a leader, liaison, and resource working collaboratively with a diverse group, including management, physicians, clinical and non-clinical personnel utilizing the national correct coding standards, approaches, and industry standard coding rules to support and expand internal and external strategies. Applies expanded knowledge of CPT, ICD-10 and HCPCS coding skills toward the maintenance and development of prospective claim edits and partnerships. Determines payment compliance with clinical and reimbursement policies. Researches CPT codes to clarify coding issues, as required. Determines opportunities with current vendor partnerships and implementations, exploring new opportunities as well. Coordinates, reviews, and recommends changes for the yearly opportunity analysis. Reviews and responds to claim edit appeals and rational requests. Coordinates, supports, and resolves vendor needs both prospectively and retrospectively. Problem solves system/claim edit issues that may come up. Tests and verifies new claim edits