Resp & Qualifications
CareFirst has corporate goals to transition from paying fee-for-service to value-based contracts. This position will act as the internal expert within the Payment Transformation team, providing the bridge between external provider claims language and the internal stakeholders. Acts as an internal expert to ensure that as value-based reimbursement models are developed and implemented Medical Affairs is partnering effectively with providers and providing guidance on the appropriate quality measure capture and proper use of CPT and ICD10 codes in claims submissions. For Medicare STARs, quality and risk adjustment purposes, we are dependent on claims coming in with appropriate ICD10 diagnosis codes, CPT codes and CPT2 codes. The incumbent will utilize their coding expertise, combined with our medical policy, credentialing, and contracting rules knowledge to build the effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity.
Under the general supervision of the Manager of Payment Transformation the incumbent’s accountabilities may include, but are not limited to, the following:
Consult on proper coding rules in value-based contracts to ensure appropriate quality measure capture and proper use of CPT and ICD10 codes. Consult on various consequences for different financial and incentive models. Strategize alternatives and solutions to maximize quality payments and risk adjustment. Translate from claim language to services in an episode or capitated payment to articulate inclusions and exclusions in models.
Serve as a technical resource / coding subject matter expert for contract pricing related issues. Conduct complex business and operational analyses to assure payments are in compliance with contract; identify areas for improvement and clarification for better operational efficiency. Provide problem solving expertise on systems issues if a code is not accepted. Troubleshoot, make recommendations and answer questions on more complex coding and billing issues whether systemic or one-off.
Develop and refine effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity. May interface directly with provider groups during proactive training events or just in time on complex claims matters. Consult with various teams, including the Practice Transformation Consultants, to interpret coding and documentation language and respond to inquiries from providers.
Participate in strategy for quality measure capture (NCQA, HEDIS, STARs). Liaise with quality and clinical innovations team and VP of STARs and Risk Adjustment on process and outcome improvement activities. Ensure compliance with all coding standards.
• At least one or more of the following Coding certifications: CCS, CCS-P, CDIP (AHIMA), CPC, CRC, CPMA (AAPC)
• 3-5 years of experience in risk adjustment coding, ambulatory coding, clinical documentation improvement
• Previous managed care, State and/or Federal health care programs (i.e., Medicaid, Medicare) or health insurance industry experience. Knowledge of billing practices for hospitals, physicians and/or ancillary providers as well as knowledge about contracting and claims processing
• Experience in revenue cycle management and value-based reimbursement/contracting models and methodologies
• Demonstrated ability to effectively analyze and present data
• Proven problem-solving skills
• Ability to create educational materials, training manuals, and/or procedural guides
• Must demonstrate resilience and effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
• Bachelor’s degree
• Experience in medical auditing
• Experience in training/education/presenting to large groups
Value Based Contracting
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship