Medical Policy & Coding Project Consultant – RN/CRNP

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🔥 0 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $72.9k - $137.3k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

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Capital Blue Cross

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1938

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Capital Blue Cross is a health insurance company that offers a range of health plans for individuals, families, and employers. They serve customers in Central Pennsylvania and the Lehigh Valley, focusing on providing health coverage services such as Medicare plans, student health plans, and resources for managing medical care. Capital Blue Cross positions itself as a partner in health, emphasizing support for members' overall wellness and preventive health measures.

📋 Description

• Lead and support cross-functional initiatives related to Medical Policy and Coding • Apply clinical care, evidence-based practice, coding, claims administration, healthcare data analysis, IT&D, and operational workflow knowledge to organizational initiatives • Research and develop clinical services aligned with evidence-based practice and benefit coverage requirements • Serve as a clinical, business, and technical resource to MPC Clinical and Coding Coordinators • Research, maintain, and identify CPT, CDT, HCPCS, ICD-10, and revenue codes • Independently manage episodic and special projects • Conduct clinical and business research and develop evidence-based policy and clinical recommendations • Draft and revise complex medical policies • Prepare recommendations for internal, client, and insurance department audits • Attend external BCBSA MPP monthly meetings and propose medical policy adoption • Conduct interdepartmental networking supporting clinical initiatives • Complete new code Phase II clinical reviews and assist with annual ICD-10 code review • Collaborate with the Coding Team Lead to provide staff training

🎯 Requirements

• Minimum of 5 years in a clinical setting and medical coding position • Preferably experience in managed care or health insurance • Five years of medical coding experience including ICD-10, CPT, CDT, HCPCS, and revenue codes preferred • Current, non-restricted clinical license • Bachelor’s Degree in Nursing required • AAPC Medical Coding certification required; employees without it may take the offered course • Continuing education credits must be satisfied to maintain AAPC certification • Professionalism when interacting with internal and external personnel • Ability to prepare written materials and oral presentations for clinical, technical, and non-technical audiences • Meeting leadership and project completion skills • Demonstrated analytical skills • Advanced problem-solving and structured analysis/design techniques • Ability to work independently with minimal supervision • Project management ability and use of project plans • Ability to handle confidential information in accordance with HIPAA and Compliance expectations • Knowledge of healthcare industry standards, policies, clinical and business practices, claims administration, provider networks, clinical operations, and SIU • Knowledge of web-based technologies, SharePoint, SAS, Microsoft Access, Microsoft Excel, reporting and testing software, and Microsoft Office Suite • Strong working knowledge of benefits, payment policies, claims operating systems, payment processes, and claims adjudication • Knowledge of government regulatory and accrediting requirements including PPACA, FEP, MS, Pennsylvania regulations, NCQA, URAC, OH, and Medical Assistance • Advanced understanding of medical terminology • Basic knowledge of treatment modalities and medical policy/benefit coverage interrelationships • Knowledge of IT&D, pre-configuration, configuration, and medical policy circulation processes • Proficiency in data analysis, data presentation, and claims-data trending through medical coding analysis

🏖️ Benefits

• Medical, Dental & Vision coverage • Retirement Plan • Paid Time Off • Holidays • Volunteer time off • Incentive Plan • Tuition Reimbursement • Flexible environment • Training and continuing education • Opportunity to volunteer in the community