GuideWell and its family of forward-thinking companies are focused on helping people and communities achieve better health and are at the forefront in the transformation of health care. We offer competitive salariesandbenefits, work-life balance,flexible work arrangements, opportunities for growth and development, and a great place to workacross our enterprise!

What is your impact?
This role will serve as Coding Consultant who advises PIO, Post-Pay Leadership, Projects, and Programs on coding and billing policies, procedures, and best practices to align with industry NCCI and CMS standards. Responsibilities will include consulting on the development of concepts and analytics, evaluation of current and new PIO programs to ensure compliance with authoritative sources, ensuring correct application of coding and billing guidelines to claim reviews. Analyze and audit PIO programs review outcomes to capture and identify risk issues, revenue leakage and educational opportunities. Consults with SIU to develop/coordinate plan of action to address providers identified by post pay audit that may be fraudulently billing. The role will serve as the designated PIO trainer for coding certifications This role requires an extensive coding knowledge, coding certification and additional specialty certifications to independently perform reviews of all assigned provider claims from a focused medical coding and provider billing perspective to ensure claims payment integrity for high-risk and high-profile claims and escalations. All audits will include reviews of corresponding medical records and clinical documentation to validate coding (specifically professional/ancillary provider type) billing appropriateness.

Important to know!

• Must have at least 3-5 AAPC Medical Coding Certifications. A CPC-I is HIGHLY preferred.
• Must have hands-on experience with Physician-based coding.
• This is an exempt, full-time position.

What will you be doing?

• Create, present and/or facilitate meetings, webinars, conference calls, training programs, education sessions, certifications, etc. for a variety of internal and external audiences. Identifies risks, suggests solutions, and trains staff to be compliant with Florida Blue guidelines, contractual requirements, industry standards & federal/state requirements. Identifies risks, suggests solutions, and trains staff to be compliant with Florida Blue guidelines, contractual requirements, industry standards & federal/state requirements. Serves as the PIO trainer for AAPC coding certification to assist PIO employees to prepare for Certification exams.
• Serves as a subject matter expert for coding aspects for Payment Intergrity department. Represent the PIO Post Pay Audit team in meetings with Providers, internal leadership and policy and Editing Governance committee. To address coding/billing issues/trends and recommendations. Lead the design and development of new audit concepts. Advise management on options, opportunities, risks, solutions, cost versus benefits and impacts on business processes, systems, employees, etc. Influence and gain acceptance of ideas and suggestions.
• Independently perform analysis of high risk and high profile claims on a post-payment basis utilizing clinical, coding and claims processing background to ensure claims are coded, billed and paid correctly
• Leverage coding expertise to audit high risk claims for inappropriate application of associated Florida Blue policies and industry standard billing and care practices that may impact claims payment (e.g. MCG, LCD, Authorizations, Covered Benefits, Appropriateness of Service Setting). Specifically:
  
  • Validate and analyze coding concepts for exceptions identified of potential issues/challenges.
  • Independently request and review pertinent medical records to validate/invalidate potential issues identified on high risk claims
  • Determine claim level financial impact based on unique member benefits and provider contract terms and payment policies.
  • Ensure claims processing compliance with overarching administrative regulations (Federal, State of Florida, etc.).
  • Ensure compliance with the BCBS Association's PI Parity Mandate requirements for auditing Host claims.
  • Perform claims level analysis of appropriate provider coding and billing practices and/or guidelines
  • Reviews claims history, medical reviews, provider files, etc
• Synthesize collected data and proactively collaborate with data team to accurately submit data requests and resolve data concerns.
• Establish and maintain contact with internal and external business partners to obtain and share information for influencing decisions, and/or providing advice and counsel that impacts business objectives related to payment policies and claims edits.
• Review escalated issues to identified over/underpayment findings to leadership that can affect change to upstream processes within Care, Network, Claims and Product where possible to increase efficiencies and reduce future potential overpayments by review of coding and medical records.

What you must have:

Required Work Experience

• 5+ years related work experience. Experience details: Medical Records Review ; Physician Ancillary based coding.

Required Education

• Related Bachelor's degree or additional related equivalent work experience

****Required Licenses and Certifications****

• Minimum of 3-5 AAPC Medical Coding Certifications
• HIGHLY PREFERRED: CPC-I - Certified Professional Coder Hold an active coding instructor certification AAPC. Upon Hire.

Additional Required Qualifications

• Strong familiarity with CPT/HCPCS coding.
• Experience with and knowledge of multiple provider reimbursement and pricing methodologies
• Demonstrated proficient working knowledge of at least three of the following: medical terminology, claim audit procedures, provider contracts, claims processing procedures and guidelines, provider authorizations, provider billing, medical coding, concurrent review.
• Strong analytics thinking and experience
• Proficiency/experience working with some of the following Tools/Apps: o Diamond o Jiva o APT o EIP o Siebel o ICN o Quest o Contract Management System o Burgess o PPS Pricer o Encoder o Alineo
• Working knowledge of COB/OPL, Subrogation and Workers' Comp, standard claims adjustment processes and benefit plans.
• Working knowledge of personal computer and related software (e.g., Excel, Microsoft Word).
• Demonstrate flexibility in unplanned work and/or project support.
• Excellent oral and written communications skills.

Preferred Education

• Master's degree

General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

Physical/Environmental Activities
Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally

What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance;
• Income protection benefits: life insurance, Short- and long-term disability programs;
• Leave programs to support personal circumstances;
• Retirement Savings Plan includes employer contribution and employer match;
• Paid time off, volunteer time off, and 11 holidays
• Additional voluntary benefits available; and
• A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Annualized Salary Range: $78,800 - $128,100

Typical Annualized Hiring Range: $78,800 - $98,500

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.