Coding & Payment Rule Specialist

Regular

Exempt

GENERAL DESCRIPTION: The Coding & Payment Rule Specialist is responsible for identifying coding guidelines established by the American Medical Association's (AMA) standard classification systems (ICD-10, CPT, HCPCS) and payment rules established by the Centers for Medicare & Medicaid Services (CMS) for the proper and timely processing of claims.

ESSENTIAL FUNCTIONS:

• Applies coding guidelines and payment rules to comply with updated healthcare reimbursement systems, including CMS (Centers for Medicare & Medicaid Services), the Physician Fee Schedule Database, and DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) schedules.
• Tracks quarterly CMS (Centers for Medicare & Medicaid Services) service code changes to systematically design, develop, and modify corresponding internal payment rules. Proactively monitors coding guidelines to detect billing issues affecting final claim payments and refers complex cases to appropriate areas for analysis.
• Completes tasks established by the company's operational readiness, which includes identifying annual coding changes and validating these changes on pre-authorization lists and the durable medical equipment formulary.
• Reviews and validates potential coding changes driven by Medicare NCD (National Coverage Determinations).
• Identifies and defines payment rules for clinical medical policy referrals.
• Receives, analyzes, and answers all referrals received in the Operational Medical Policy unit regarding payment of a claim.
• Receives, analyzes, and responds to inquiries received from the Provider units relations regarding payment rules and coding guidelines that impact contracting.
• Evaluates post-service appeals and timely payment grievances received within the established timeframe, analyzing the correct payment rule and coding.
• Serves as a facilitator in educational activities to providers and internal company areas regarding correct coding, including, but not limited to CPT, IDC10, HCPCS, DRG, and APC.
• Develops payment rules for educational material and publishes the same for both internal and external accessibility for providers.
• Requests the implementation of the payment rule in the corresponding systems and provides follow-up for its validation in coordination with the Systems Configuration department. Performs testing scenarios and validation for the updates of the editing systems. Identifies findings in the editing and payment systems and supports in resolving them to avoid impact on claims and payments to the provider.
• Analyzes and manages medical appeals in accordance with DRG (Diagnosis-Related Group) reimbursement methodology, ensuring accurate application of coding, billing, and payment guidelines while maintaining compliance with regulatory and organizational requirements.
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS: Education and Experience: Bachelor’s degree in Business Administration. At least three (3) years of experience in coding and payment rules, or related areas.

OR Education and Experience: Associate degree or 60-64 approved college credits in Health Information Technology or Coder Technician. At least four (4) years of experience in coding and payment rules.

“Proven experience may be replaced by previously established requirements.” Certifications/Licenses: Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician (CCS-P) is preferred. Other: Previous experience with claims editing and processing systems.

Languages: Spanish – Advanced (comprehensive, writing and verbal)

English – Advanced (comprehensive, writing and verbal)

“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”