Clinical Policy Coding Administrator

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About the role of Clinical Policy Coding Administrator

The Clinical Policy Coding Administrator is a senior member of the Medical Policy and Clinical Coding team whose work is critical in managing healthcare costs. In this compelling and challenging role, you will work with a dynamic team of experts that pull together medical policy operations and clinical expertise to make decisions that ensure members receive safe services and accurate payment for those services. The Clinical Policy Coding Administrator will focus on identifying and coordinating appropriate codes to support claim system edits that direct payment of medical services. This individual will be a liaison between the clinical and operations teams, working to bring the two aspects of the business together to inform configuration that supports accurate claims processing. Act as a key resource and contact for clinical coding, the Clinical Policy Coding Administrator will draw on their knowledge of medical policy and clinical coding to identify the appropriate codes that accurately represent services. Collaboration with configuration teams (i.e.., Claims and Product) is vital to ensure codes are established in the system in order to pay claims appropriately.

What you’ll do:

• Collect and analyze data to evaluate the effectiveness of medical policy implementation, identify and update appropriate procedure and diagnosis codes, and support business decisions regarding utilization management activities and guidelines.
• Support medical policy development and implementation by identifying and updating appropriate procedure and diagnosis codes for company medical policies and UM (Utilization Management) guidelines that reflect medical necessity, experimental/investigational or other code categories.
• Provide subject matter expertise for the Medical Policy Implementation Workgroup to ensure cross-functional collaboration between Clinical Review, Healthcare Services, and other departments on coding edit decision-making related to medical policies and mitigate downstream impact.
• Perform analysis, research, and assessment in response to cross-functional requests to inform accuracy and consistency for claims processing, reimbursement, benefit, and product configuration issues.
• Develop and use data gathering tools to document and analyze patterns of code payments and denials, medical policy changes, and coding changes.
• Research and interpret medical claims utilization and program participation. Present findings to internal customers to assist them in managing healthcare costs and improved member satisfaction.
• Identify potential patterns and/or trending to confirm alignment of code payments, changes and denials, and medical policy changes.
• Contribute to the analysis and decision-making efforts of the provider appeal process including assessment of appropriate codin