Healthcare Clinical Editing Claims Analyst at Strategic Staffing Solutions
Detroit, MI
About the Job
STRATEGIC STAFFING SOLUTIONS (S3) HAS AN OPENING!
Title: Healthcare Clinical Editing Claims Analyst
Location: Detroit, MI (Remote/Must be local to Michigan)
Duration: 12+ Months
Role Type: W2 Contract Engagement
Role Summary
This position is primarily responsible for the coordination of activities within the clinical editing unit. This area is responsible for the development, implementation and decision-making related to the clinical editing software utilized by the health plan to determine the appropriateness of billing and reimbursement within said parameters. These parameters include clinical edits, multi-line surgery claims and daily limit processing (dlp), as well as related provider appeals. There is an emphasis on report analysis to determine appropriate payment levels based on standard billing practices and medical coding standards. Related technical expertise is available and is provided to internal departments.
Requirements:
• Associate degree or two years of college required with a preferred area of concentration in business, information systems or a health care related field. Bachelor degree preferred.
• ICD 9-CM and CPT courses required; may consider two years’ experience with these manuals in lieu of classes.
• Coding certification preferred (eg, CPC certification).
• Minimum of four years in any combination of the following: Billing and coding experience (preferably in a comprehensive surgical center or facility), Claims resolution (including adjudication, coding, thorough analysis and problem-solving).
• Experience in spreadsheet development, word processing and database software; Windows environment and ACCESS preferred.
• Working knowledge of medical coding standards, including HCPCS, CPT, ICD-9, etc.
• Knowledge of NCQA, CMS, State and Federal HMO regulations preferred.
• Knowledge and understanding of provider coding and billing practices and systems logic for reimbursement.
• Analytical and problem-solving skills to evaluate and implement version upgrades (pre and post implementation).
• Maintenance of documentation, including completion of logs and database, Microsoft Access, FACETS entry, letter generation, etc., related to appeals and inquiries.
• Analysis of reports, appeals and inquiries, related to clinical edits, dlp and clinical editing activities.
• Handling and resolutions of issues identified on reports.
• Resolution documented in accord with established processes.
• Handling and resolution of inquiries from sources, primarily internal – ensuring consistent application of clinical editing criteria and explanation of same.
Education:
• Associate’s Degree in business or health care related field.
• Three (3) years related experience in managed care operations including specific functional experience related to assigned department.
*Beware of scams. S3 never asks for money during its onboarding process
The S3 Difference
The global mission of S3 is to build trusting relationships and deliver solutions that positively impact our customers, our consultants, and our communities. The four pillars of our company are to:
• Set the bar high for what a company should do
• Create jobs
• Offer people an opportunity to succeed and change their station in life
• Improve the communities where we live and work through volunteering and charitable giving
As an S3 employee, you’re eligible for a full benefits package that may include:
• Medical Insurance
• Dental Insurance
• Vision Insurance
• 401(k) Plan
• Vacation Package
• Life & Disability Insurance Plans
• Flexible Spending Accounts
• Tuition Reimbursement
