Coding and Cost Analyst I, Geisinger Health Plan (Easter Standard Time Zone res

Location: Work from home (Pennsylvania) Shift: Days (United States of America) Scheduled Weekly Hours: 40 Worker Type: Regular Exemption Status: No Job Summary: Contributes to the achievement of the strategic and financial goals of the organization by conducting thorough reviews of billed services, authorizations, plan benefit documents, itemized statements, medical records, discharge summaries and detailed data reports. Makes reimbursement or recovery recommendations based on appropriate coding, billed statistics, policies, industry standards and compliance with contractual, state, and federal regulations. Job Duties: Supports and serves as a resource to other Health Plan departments by providing review and recommendation for correct coding, appropriate billing, and reimbursement. Completes clinical reviews related to Claims, Claim Edits, Appeals and the Grievance process, assisting in analysis of clinical risk related to Underwriting, Pharmacy, and Finance departments. Recommends recovery efforts based on current contracts, policies, procedures and accepted industry standards. Reviews and validates pended and reconsidered claims when edits are applied by the Plan claim editing software from multiple vendors. Reviews are typically based on CPT guidelines, industry standards and CMS guidelines. Completes reviews on inpatient and outpatient high dollar claims following internal guidelines. Assists in reviews of quality concerns. Validates claim payments based on Plan contracts