Medical Policy Reviewer

2 days ago

Taguig, National Capital Region, Philippines UST Full time

Responsibilities:

  • Develop full understanding of each medical and claim payment policy, to ensure accurate diagnosis and procedure code assignment. Understand CMS/regulatory requirements, IBX/AH benefit structure, managed care rules (e.g., HMO Capitation, PPO Network Rules) and other business rules to assure diagnosis and procedure code alignment
  • Real-time collaboration with clinical policy writers and business analysts to assist in the development of business requirements to support medical code setup in the claim system in alignment with policy requirements
  • Present medical and claim payment policy coding determinations with supporting rationale on a twice weekly cadence for intradepartmental review and approval. Presentation and discussion at this forum help to reduce coding errors that directly impact compliance, claim outcomes, and member/provider experience. Such errors can expose the company to compliance issues with CMS, state and federal laws, and other governing entities
  • Support responses to medical and claim payment coding questions from the internal Medical and Claim Payment Policy Committee and the external Clinical Policy and Utilization Management Committee members, during the committee review processes
  • Support medical code assignment for self-funded group customized benefit requirements. Work in conjunction with IBX/AH Sales team and Product Operations to understand benefit structure and provide rationale for code identification
  • Support medical code assignment for state and federal mandates, and other regulatory matters
  • Respond to medical code assignment inquiries requiring expedited review for services/surgeries pending prior-authorization and/or pricing determinations. This requires review of member clinical records held to HIPAA standards of confidentiality and privacy
  • Analyze reporting practices, claims utilization, and system implementation data to make recommendations for policy enforcement, identify claims processing errors, perform root cause analyses, and support HVO cost-savings opportunities
  • Review and resolve Service Now tickets or claim processing errors received through inquiry process

Qualifications:

  • Min of 1 year experience as a QA/OR in any coding field
  • Min of 3 years medical coding experience (In-Patient, Outpatient)
  • Experience and must have good understanding of the claims guidelines (Facility and Provider)
  • Active coding certification under AAPC or AHIMA.
  • Able to code using ICD-10 CM physical codebook or coding software
  • Strong clinical knowledge related to chronic illness diagnosis, treatment and management

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