Expert Coding Consultant / Client Policy Manager
Identify changes needed to client policies to maintain up-to-date and accurate medical payment policies. Coordinate and partcipate in monthly/quarterly client policy meetings. Review client payment policies for accuracy and make important decisions to ensure the integrity of the client is maintained. Present medical policies for review and acceptance by the client, as well as provide direction to the client to aid in understanding of medical policies. Create value for the clients with ad hoc data analysis, including claims analysis, provider trends and identify aberrant coding. Identify necessary changes to existing library claim edits and identify potential new edits through researching, reviewing and interpreting coding and billing professional journals/industry publications, periodicals, and governmental regulations. Develop client specific edits through reviewing of claims data, targeting problem areas of monetary loss. Perform follow-up with Medical Directors to ensure reviews are completed on a timely basis. Responsible for initiating data analyses and claims analyses for new issue development. Review claims analysis results for identification of potential new issues, areas for provider education, or areas for recoupment of incorrectly paid claims. Provide training material for customer service reps on iHT administered edits. Monitors edit trends for potential logic modification. Coordinate all issues and activities within iHT and between iHT and the client. Address inquiries relating to edits administered by iHT. Considered the 'subject matter expert', within the company internally, as well as externally (client). Attend and involved in Steering Committee meetings and Operational Meetings on a monthly basis. Assist with the Implementation Department to ensure that all edits for new clients are compliant with the state laws, mandates and the client's internal policies (i.e. prior authorization, non-covered procedures, etc.