Edit Resolution Analyst

4 days ago

Taguig, National Capital Region, Philippines Conifer Health Solutions Full time ₱800,000 - ₱1,200,000 per year

This position is responsible for identifying, capturing, tracking, reviewing, and resolving held claim edits, claim rejections, and/or denials that result from the claims/billing cycle. This position ensures all resolutions utilized are in accordance with policies, procedures, official coding guidelines/advice, rules and regulations (payer, state, and/or federal). Position requires a working knowledge of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes and any appropriate modifiers, various payment methodologies, as well as working knowledge of appropriate, compliant hospital and provider billing and charging practices.

  • Identifies, tracks, and reviews revenue cycle held claim edits, rejections, and/or denials including verifying legal health record documentation to identify appropriate resolution and/or preventative solution to the identified claim/billing edits, errors, omissions, rejections, and/or denials including correcting and resubmitting the claim. This may include data quality reviews on diagnosis and procedure codes and/or charges as well as addressing NCCI (national correct coding initiative), OCE (outpatient code editor), NCD (national coverage determination), and LCD (local coverage determination) edits as appropriate to the edit, rejection, and/or denial worked. Verifies all worked claims are to the payer within timely filing limits. Meets and/or exceeds established productivity and quality standards. Adheres to Standards of Ethical Coding as set for by the American Health Information Management Association.
  • Identifies, tracks, and monitors any revisions and/or corrections they make to the claims processing system to ensure corrections occur in a timely manner. In-depth critical thinking, research, and analysis is required. Strong working knowledge of ICD-10-CM, ICD-10-PCS, HCPCS, CPT codes, modifiers, charging, and payment methodologies are essential.
  • Maintain proficiency in injection and infusion CPT coding/charging and abstracting to identify procedures performed.

Work Experience:

  • 2 or more years of direct, recent experience in a hospital setting, healthcare industry, revenue cycle, revenue integrity and/or coding operations resolving held claims with a focus in two or more of the following areas: coding, coding quality/compliance, documentation integrity, charge validation, charge/revenue integrity, charge compliance, charge audit, CDM management/maintenance and/or denials prevention/management.
  • 3 or more years' recent experience in ICD, CPT, and HCPCS proficient code assignment including, but not limited to, Evaluation & Management codes (technical and professional), injection and infusion coding guidelines, interventional services, observation services, as well as appropriate modifier assignment.
  • Experience in a complex multi-entity organization or with large complex revenue cycle services preferred.
  • Proficient in compliant charging and billing practices.
  • Proficient in state and federal charging and billing regulations.

Required Certification/ Licensure:

  • Professional certification through AHIMA (RHIA, RHIT, CCS, CCS-P) and/or AAPC (CPC, COC, or CIC) required. Will consider years of direct, relevant experience in lieu of certification. Active certification from AHIMA or AAPC is required within one year of employment.
  • Nursing education/licensure desirable (i.e. RN, LPN, LVN)

Working Conditions:

  • Amenable to work onsite in BGC, Taguig
  • Willing to work in a dayshift schedule

Company Benefits:

  • Competitive Salary
  • HMO plus free dependents
  • Group life insurance
  • PTO Credits
  • Annual Appraisal
  • Annual Performance Bonus

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