FREE ACCESS
5,000–10,000 jobs/day
See all jobs on Scoutfield
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Medical Policy Development, CPT Coding, and Medical Claims Analysis, ensuring compliance with coding guidelines and benefit configuration. Proficient in auditing claims and managing databases to support operational efficiency and policy implementation.
Highest-signal resume keywords
CPT CodingMedical Claims AnalysisBenefit ConfigurationMedical Policy ImplementationClaims Auditing
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
CPT CodingMedical ClaimsBenefit ConfigurationClaims AuditingData AnalysisCompliance ReviewCoding GuidelinesDatabase ManagementClaims ProcessingUtilization Review
Soft Skills
CommunicationLeadershipHealth Care Policy And Ethics Compliance
Tools & Technologies
Facets Workflow
Industry Keywords
Medical PolicyCoding GuidelinesClaims PaymentContractual ComplianceState ComplianceFederal ComplianceOperational DeficienciesProcess ImprovementBenefit SetupAd Hoc Reporting
About the role
Key responsibilities & impact- Support Medical Policy/Clinical Guidelines development efforts
- Investigate and audit medical claims related to medical policy changes
- Analyze claims data to guide policy development and revision
- Investigate coverage status using medical policies, coding guidelines, and industry information
- Advise on benefit configuration by line of business
- Maintain repositories for code configuration changes resulting from medical policy development and government directives
- Research and retrospectively review medical claims for contractual, state, and federal compliance
- Request and review medical records to validate services billed with unlisted or miscellaneous codes
- Research reimbursement, medical record documentation, utilization, and proper coding
- Review clinical documentation to determine coverage eligibility
- Recommend system setup for proper claims adjudication and benefit coverage
- Develop and maintain databases cataloging code status related to medical policy and mandates
- Manage coding matrices and databases for vendors, prior authorization, preventive services, non-covered services, and experimental, investigational, or unproven services
- Present to committees regarding benefit and claims configuration
- Produce ad hoc reports on pre- and post-implementation utilization trends
- Identify operational deficiencies and process improvement opportunities
- Coordinate implementation of annual new codes and quarterly updates
- Assign new coding to treatment types to ensure appropriate cost-sharing tiers
- Audit claims for compliance with coding guidelines and Health Plan policies
- Address claims payment errors identified through audits and retrospective reviews
- Process claims in Facets workflow requiring manual review
- Review claim research request forms for claim adjustment determinations
- Provide CPT/HCPCS code advisement to GHP workgroups
- Participate in standing GHP operational meetings as needed
Requirements
What you’ll need- High School Diploma or Equivalent (GED) (Required)
- Minimum of 2 years of relevant experience (Required)
- Eastern Standard Time Zone resident
- Experience with CPT coding, Medical Claims, and Benefit Configuration preferred
- Knowledge of medical policy implementation, coding guidelines, medical claims payment, claim edits, and benefit setup
- Communication, Health Care Policy And Ethics Compliance, and Leadership skills
Benefits
Comp & perks- Healthcare benefits for full-time and part-time positions from day one
- Vision benefits
- Dental benefits
- Domestic partner benefits
- Collaborative, cooperative, and collegial work atmosphere