Claim Specialist

• Collaborate with external vendors in healthcare claims or payment integrity, including implementation support, claim-edit validation, issue escalation and resolution, performance monitoring, and vendor relationship management
• Lead and support internal and external claims-edit strategies using coding standards and industry rules
• Maintain and develop prospective claim edits and vendor partnerships using CPT, ICD-10, and HCPCS coding
• Determine payment compliance with clinical and reimbursement policies
• Research CPT codes and clarify coding issues
• Identify opportunities with current vendor partnerships and explore new opportunities
• Coordinate, review, and recommend changes for the yearly opportunity analysis
• Review and respond to claim-edit appeals and rational requests
• Coordinate, support, and resolve vendor needs prospectively and retrospectively
• Troubleshoot system and claim-edit issues
• Test and verify new claim edits during maintenance and vendor implementation
• Lead the Edit Expansion Committee and routine vendor-partner maintenance and oversight meetings
• Serve as a subject matter expert for internal workgroups and committees
• Clarify documentation and billing issues with providers and Account Managers
• Lead internal development, testing, maintenance, and expansion of claims edits
• Lead development of the ClaimsXten Policy Management Module
• Mentor less experienced staff and new hires
• Compile and coordinate routine performance reporting for vendor initiatives and support report-out meetings

Explore Claim Edit and Vendor Integrity Specialist at Geisinger. Review requirements and application details.